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

X12 Release 5010

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

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
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    Overview
    ISA
    -
    Interchange Control Header
    Max use 1
    Required
    GS
    -
    Functional Group Header
    Max use 1
    Required
    heading
    detail
    Information Source Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    AAA
    0250
    Request Validation
    Max use 9
    Optional
    Information Receiver Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    Subscriber Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    TRN
    0200
    Subscriber Trace Number
    Max use 3
    Optional
    Subscriber Name Loop
    NM1
    0300
    Subscriber Name
    Max use 1
    Required
    REF
    0400
    Subscriber Additional Identification
    Max use 9
    Optional
    N3
    0600
    Subscriber Address
    Max use 1
    Optional
    N4
    0700
    Subscriber City, State, ZIP Code
    Max use 1
    Optional
    AAA
    0850
    Subscriber Request Validation
    Max use 9
    Optional
    PRV
    0900
    Provider Information
    Max use 1
    Optional
    DMG
    1000
    Subscriber Demographic Information
    Max use 1
    Optional
    INS
    1100
    Subscriber Relationship
    Max use 1
    Optional
    HI
    1150
    Subscriber Health Care Diagnosis Code
    Max use 1
    Optional
    DTP
    1200
    Subscriber Date
    Max use 9
    Optional
    MPI
    1275
    Subscriber Military Personnel Information
    Max use 1
    Optional
    Dependent Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    TRN
    0200
    Dependent Trace Number
    Max use 3
    Optional
    Dependent Name Loop
    NM1
    0300
    Dependent Name
    Max use 1
    Required
    REF
    0400
    Dependent Additional Identification
    Max use 9
    Optional
    N3
    0600
    Dependent Address
    Max use 1
    Optional
    N4
    0700
    Dependent City, State, ZIP Code
    Max use 1
    Optional
    AAA
    0850
    Dependent Request Validation
    Max use 9
    Optional
    PRV
    0900
    Provider Information
    Max use 1
    Optional
    DMG
    1000
    Dependent Demographic Information
    Max use 1
    Optional
    INS
    1100
    Dependent Relationship
    Max use 1
    Optional
    HI
    1150
    Dependent Health Care Diagnosis Code
    Max use 1
    Optional
    DTP
    1200
    Dependent Date
    Max use 9
    Optional
    MPI
    1275
    Dependent Military Personnel Information
    Max use 1
    Optional
    SE
    4100
    Transaction Set Trailer
    Max use 1
    Required
    GE
    -
    Functional Group Trailer
    Max use 1
    Required
    IEA
    -
    Interchange Control Trailer
    Max use 1
    Required
    ISA

    Interchange Control Header

    RequiredMax use 1

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

    Example
    ISA-01
    I01
    Authorization Information Qualifier
    Required

    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
    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

    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
    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
    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
    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
    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
    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
    YYMMDD format

    Date of the interchange

    ISA-10
    I09
    Interchange Time
    Required
    HHMM format

    Time of the interchange

    ISA-11
    I65
    Repetition Separator
    Required
    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

    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
    Min 9Max 9

    A control number assigned by the interchange sender

    ISA-14
    I13
    Acknowledgment Requested
    Required
    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
    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
    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

    Code identifying a group of application related transaction sets

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

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

    GS-03
    124
    Application Receiver's Code
    Required
    Min 2Max 15

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

    GS-04
    373
    Date
    Required
    CCYYMMDD format

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

    GS-05
    337
    Time
    Required
    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
    Min 1Max 9

    Assigned number originated and maintained by the sender

    GS-07
    455
    Responsible Agency Code
    Required
    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

    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
    ANSI ASC X12.281 Eligibility, Coverage, or Benefit Inquiry (270) and ANSI ASC X12.282 Eligibility, Coverage, or Benefit Information (271) mandated under HIPAA through June 2010

    Heading

    ST
    0100

    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

    Code uniquely identifying a Transaction Set

    • The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
    Usage notes
    • Use this code to identify the transaction set ID for the transaction set that will follow the ST segment. Each X12 standard has a transaction set identifier code that is unique to that transaction set.
    271
    Eligibility, Coverage or Benefit Information
    ST-02
    329
    Transaction Set Control Number
    Required
    Min 4Max 9

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

    Usage notes
    • The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example "0001", and increment from there.
    ST-03
    1705
    Implementation Convention Reference
    Required

    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

    Beginning of Hierarchical Transaction

    RequiredMax use 1

    To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

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

    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

    Code identifying purpose of transaction set

    06
    Confirmation

    Use this code only to acknowledge the successful cancellation of a 270 transaction that was received with a BHT02 value of "01" Cancellation.

    11
    Response
    BHT-03
    127
    Submitter Transaction Identifier
    Optional
    Min 1Max 50

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

    • BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
    Usage notes
    • This information may be sent at the creator of the 271's discretion if using the transaction in a Batch mode and a Submitter Transaction Identifier was received in the 270 transaction BHT03, otherwise this is not used. Due to the nature of batch transaction processing, the receiver of the 270 transaction (whether it is a clearinghouse or information source) may or may not be able to return the 270 BHT03 value in the 271 BHT03. See Section 1.4.6 Information Linkage for additional information and requirements.
    • This element is to be used to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. This identifier is to be the identifier received in the BHT03 of the corresponding 270 transaction. This identifier is not to be passed through the complete life of the transaction, rather replaced with the identifier received in the 270.
    BHT-04
    373
    Transaction Set Creation Date
    Required
    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
    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.

    Detail

    2000A Information Source Level Loop
    RequiredMax >1
    HL
    0100

    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
    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

    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

    Code indicating if there are hierarchical child data segments subordinate to the level being described

    • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
    0
    No Subordinate HL Segment in This Hierarchical Structure.
    1
    Additional Subordinate HL Data Segment in This Hierarchical Structure.
    AAA
    0250

    Request Validation

    OptionalMax use 9

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

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

    Code indicating a Yes or No condition or response

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

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

    Y
    Yes

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

    AAA-03
    901
    Reject Reason Code
    Required

    Code assigned by issuer to identify reason for rejection

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

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

    41
    Authorization/Access Restrictions

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

    42
    Unable to Respond at Current Time

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

    79
    Invalid Participant Identification

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

    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

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

    Information Source Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

    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

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

    NM1-05
    1037
    Information Source Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Information Source Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    Usage notes
    • Use this element to qualify the identification number submitted in NM109. This is the number that the information source associates with the information receiver. Because only one number can be submitted in NM109, the following hierarchy must be used. Additional identifiers are to be placed in the REF segment. If the information receiver is a provider and the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate, code value "XX" must be used. Otherwise, one of the following codes may be used with the following hierarchy applied: Use the first code that applies: "SV", "PP", "FI", "34". The code "SV" is recommended to be used prior to the mandated use of the National Provider ID.

    Use "PI" when Information Receiver is a payer and "XV" is not used.

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

    If the information receiver is an employer, use code value "24".

    24
    Employer's Identification Number
    46
    Electronic Transmitter Identification Number (ETIN)
    FI
    Federal Taxpayer's Identification Number
    NI
    National Association of Insurance Commissioners (NAIC) Identification
    PI
    Payor Identification
    XV
    Centers for Medicare and Medicaid Services PlanID
    XX
    Centers for Medicare and Medicaid Services National Provider Identifier
    NM1-09
    67
    Information Source Primary Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    PER
    0800

    Information Source Contact Information

    OptionalMax use 3

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

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

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

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

    Free-form name

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

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

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

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

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

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

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

    Request Validation

    OptionalMax use 9

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

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

    Code indicating a Yes or No condition or response

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

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

    Y
    Yes

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

    AAA-03
    901
    Reject Reason Code
    Required

    Code assigned by issuer to identify reason for rejection

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

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

    41
    Authorization/Access Restrictions

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

    42
    Unable to Respond at Current Time

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

    79
    Invalid Participant Identification

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

    80
    No Response received - Transaction Terminated

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

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

    T4
    Payer Name or Identifier Missing

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

    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

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

    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
    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
    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

    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

    Code indicating if there are hierarchical child data segments subordinate to the level being described

    • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
    0
    No Subordinate HL Segment in This Hierarchical Structure.
    1
    Additional Subordinate HL Data Segment in This Hierarchical Structure.
    2100B Information Receiver Name Loop
    RequiredMax 1
    NM1
    0300

    Information Receiver Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Use this segment to identify an entity by name and/or identification number. This NM1 loop is used to identify the eligibility/benefit information receiver (e.g., provider, medical group, IPA, or hospital).
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

    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

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

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

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

    Usage notes
    • Use this element to qualify the identification number submitted in NM109. This is the number that the information source associates with the information receiver. Because only one number can be submitted in NM109, the following hierarchy must be used. Additional identifiers are to be placed in the REF segment. If the information receiver is a provider and the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate, code value "XX" must be used. Otherwise, one of the following codes may be used with the following hierarchy applied: Use the first code that applies: "SV", "PP", "FI", "34". The code "SV" is recommended to be used prior to the mandated use of the National Provider ID.

    Use "PI" when Information Receiver is a payer and "XV" is not used.

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

    If the information receiver is an employer, use code value "24".

    24
    Employer's Identification Number

    Use this code only when the 270/271 transaction sets are used by an employer inquiring about eligibility and benefits of their employees.

    34
    Social Security Number

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

    FI
    Federal Taxpayer's Identification Number
    PI
    Payor Identification

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

    PP
    Pharmacy Processor Number
    SV
    Service Provider Number

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

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

    Code identifying a party or other code

    REF
    0400

    Information Receiver Additional Identification

    OptionalMax use 9

    To specify identifying information

    Usage notes
    • Use this segment when needed to convey other or additional identification numbers for the information receiver. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100B loop.
    • Required when this information was used from the 270 transaction to identify the Information Receiver. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
    Example
    At least one of Information Receiver Additional Identifier (REF-02) or Information Receiver Additional Identifier State (REF-03) is required
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    Usage notes
    • Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
    • Only one occurrence of each REF01 code value may be used in the 2100B loop.
    0B
    State License Number

    The state assigning the license number must be identified in REF03.

    1C
    Medicare Provider Number
    1D
    Medicaid Provider Number
    1J
    Facility ID Number
    4A
    Personal Identification Number (PIN)
    CT
    Contract Number
    EL
    Electronic device pin number
    EO
    Submitter Identification Number
    HPI
    Centers for Medicare and Medicaid Services National Provider Identifier

    The Centers for Medicare and Medicaid Services National Provider Identifier may be used in this segment prior to being mandated for use.

    JD
    User Identification
    N5
    Provider Plan Network Identification Number
    N7
    Facility Network Identification Number
    Q4
    Prior Identifier Number
    SY
    Social Security Number

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

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

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

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

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

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

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

    N3
    0600

    Information Receiver Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • Required when this information was used from the 270 transaction to identify the Information Receiver. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
    Example
    N3-01
    166
    Information Receiver Address Line
    Required
    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
    Min 1Max 55

    Address information

    N4
    0700

    Information Receiver City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • Required when this information was used from the 270 transaction to identify the Information Receiver. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
    Example
    Only one of Information Receiver State Code (N4-02) or Country Subdivision Code (N4-07) may be present
    If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
    N4-01
    19
    Information Receiver City Name
    Required
    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
    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
    Min 3Max 15

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

    N4-04
    26
    Country Code
    Optional
    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
    Min 1Max 3

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    AAA
    0850

    Information Receiver Request Validation

    OptionalMax use 9

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

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

    Code indicating a Yes or No condition or response

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

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

    Y
    Yes

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

    AAA-03
    901
    Reject Reason Code
    Required

    Code assigned by issuer to identify reason for rejection

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

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

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

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

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

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

    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

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

    Information Receiver Provider Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

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

    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

    Code qualifying the Reference Identification

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

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

    Usage notes
    • Use this number for the reference number as qualified by the preceding data element (PRV02).
    2000C Subscriber Level Loop
    OptionalMax >1
    HL
    0100

    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
    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
    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

    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

    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

    Subscriber Trace Number

    OptionalMax use 3

    To uniquely identify a transaction to an application

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

    Code identifying which transaction is being referenced

    1
    Current Transaction Trace Numbers

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

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

    2
    Referenced Transaction Trace Numbers

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

    TRN-02
    127
    Trace Number
    Required
    Min 1Max 50

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

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

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

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

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

    • TRN04 identifies a further subdivision within the organization.
    2100C Subscriber Name Loop
    RequiredMax 1
    NM1
    0300

    Subscriber Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    IL
    Insured or Subscriber
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    2
    Non-Person Entity
    NM1-03
    1035
    Subscriber Last Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    Usage notes
    • Use this name for the subscriber's last name.
    NM1-04
    1036
    Subscriber First Name
    Optional
    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
    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
    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

    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
    Min 2Max 80

    Code identifying a party or other code

    Usage notes
    • Use this code for the reference number as qualified by the preceding data element (NM108).
    REF
    0400

    Subscriber Additional Identification

    OptionalMax use 9

    To specify identifying information

    Usage notes
    • Required when the Information Source requires additional identifiers necessary to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7);
      OR
      Required when the 270 request contained a REF segment with a Patient Account Number in Loop 2100C/REF02 with REF01 equal EJ;
      OR
      Required when the 270 request contained a REF segment and the information provided in that REF segment was used to locate the individual in the information source's system (See Section 1.4.7).
      If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
    • If the 270 request contained a REF segment with a Patient Account Number in REF02 with REF01 equal EJ, then it must be returned in the 271 transaction using this segment if the patient is the Subscriber. The Patient Account Number in the 271 transaction must be returned exactly as submitted in the 270 transaction.
    • Use this segment to supply an identification number other than or in addition to the Member Identification Number. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100C loop.
    • Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Numbers are to be provided in the NM1 segment as a Member Identification Number when it is the primary number an information source knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
    Example
    At least one of Subscriber Supplemental Identifier (REF-02) or Plan, Group or Plan Network Name (REF-03) is required
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    1W
    Member Identification Number

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

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

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

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

    CE
    Class of Contract Code

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

    CT
    Contract Number

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

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

    See segment note 3.

    GH
    Identification Card Serial Number

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

    HJ
    Identity Card Number

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

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

    See segment note 3.

    Q4
    Prior Identifier Number

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

    SY
    Social Security Number

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

    Y4
    Agency Claim Number

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

    REF-02
    127
    Subscriber Supplemental Identifier
    Required
    Min 1Max 50

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

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

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

    N3
    0600

    Subscriber Address

    OptionalMax use 1

    To specify the location of the named party

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

    Address information

    Usage notes
    • Use this information for the second line of the address information.
    N4
    0700

    Subscriber City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • Required when the Subscriber is the patient or when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7),
      OR
      Required if a rejection response is generated and this segment was present in the 270 and is the cause of the rejection.
      If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.;
    • Do not return address information from the 270 request unless the transaction is rejected and the rejection was caused by the address and this segment was present in the 270. See Section 1.4.7.1 271 item 7 for additional information.
    • Use this segment to identify address information for a subscriber.
    Example
    Only one of Subscriber State Code (N4-02) or Subscriber Country Subdivision Code (N4-07) may be present
    If Subscriber Country Subdivision Code (N4-07) is present, then Subscriber Country Code (N4-04) is required
    N4-01
    19
    Subscriber City Name
    Required
    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
    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
    Min 3Max 15

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

    N4-04
    26
    Subscriber Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    AAA
    0850

    Subscriber Request Validation

    OptionalMax use 9

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

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

    Code indicating a Yes or No condition or response

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

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

    Y
    Yes

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

    AAA-03
    901
    Reject Reason Code
    Required

    Code assigned by issuer to identify reason for rejection

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

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

    42
    Unable to Respond at Current Time

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

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

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

    60
    Date of Birth Follows Date(s) of Service
    61
    Date of Death Precedes Date(s) of Service
    62
    Date of Service Not Within Allowable Inquiry Period
    63
    Date of Service in Future
    71
    Patient Birth Date Does Not Match That for the Patient on the Database

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

    72
    Invalid/Missing Subscriber/Insured ID

    Required when the transaction was rejected when the information source cannot find a match for the Subscriber/Insured ID number submitted or if the ID submitted was formatted incorrectly or missing.

    73
    Invalid/Missing Subscriber/Insured Name

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

    74
    Invalid/Missing Subscriber/Insured Gender Code
    75
    Subscriber/Insured Not Found

    Code 75 may not be returned if the information receiver submitted all four pieces of the mandated search option.

    76
    Duplicate Subscriber/Insured ID Number
    78
    Subscriber/Insured Not in Group/Plan Identified
    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

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

    Use only when AAA03 is "42".

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

    Use only when AAA03 is "42".

    PRV
    0900

    Provider Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

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

    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

    Code qualifying the Reference Identification

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

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

    Usage notes
    • Use this number for the reference number as qualified by the preceding data element (PRV02).
    DMG
    1000

    Subscriber Demographic Information

    OptionalMax use 1

    To supply demographic information

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

    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
    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

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    U
    Unknown
    INS
    1100

    Subscriber Relationship

    OptionalMax use 1

    To provide benefit information on insured entities

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

    Code indicating a Yes or No condition or response

    • INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
    Y
    Yes
    INS-02
    1069
    Individual Relationship Code
    Required

    Code indicating the relationship between two individuals or entities

    18
    Self
    INS-03
    875
    Maintenance Type Code
    Optional

    Code identifying the specific type of item maintenance

    001
    Change
    INS-04
    1203
    Maintenance Reason Code
    Optional

    Code identifying the reason for the maintenance change

    25
    Change in Identifying Data Elements

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

    INS-17
    1470
    Birth Sequence Number
    Optional
    Min 1Max 9

    A generic number

    • INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
    Usage notes
    • Use to indicate the birth order in the event of multiple birth's in association with the birth date supplied in DMG02.
    HI
    1150

    Subscriber Health Care Diagnosis Code

    OptionalMax use 1

    To supply information related to the delivery of health care

    Usage notes
    • Required when an HI segment was received in the 270 and if the information source uses the information in the determination of the eligibility or benefit response for the subscriber. All information used from the HI segment of the 270 used in the determination of the eligibility or benefit response for the subscriber must be returned. If information was provided in an HI segment of 270 but was not used in the determination of the eligibility or benefits for the subscriber it must not be returned. The information source must not use information in an HI segment of the 270 transaction in the determination of eligibility or benefits for the subscriber if that information cannot be returned in the 271 response.
      OR
      Required when needed to identify limitations in the benefits identified in the 2110C loops, such as if benefits are limited for a specific diagnosis code if the information source can support this high level functionality. If the information source cannot support this high level functionality, do not send.
    • Use the Diagnosis code pointers in 2110C EB14 to identify which diagnosis code or codes in this HI segment relates to the information provided in the EB segment.
    • Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
    Example
    HI-01
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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

    Subscriber Date

    OptionalMax use 9

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

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

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

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

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

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

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

    • DTP02 is the date or time or period format that will appear in DTP03.
    Usage notes
    • Use this code to specify the format of the date(s)/time(s) that follow in the next data element.
    D8
    Date Expressed in Format CCYYMMDD
    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
    DTP-03
    1251
    Date Time Period
    Required
    Min 1Max 35

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

    Usage notes
    • Use this date for the date(s) as qualified by the preceding data elements.
    MPI
    1275

    Subscriber Military Personnel Information

    OptionalMax use 1

    To report military service data

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

    A code to indicate the status of information

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

    Code showing the general employment status of an employee/claimant

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

    Code specifying the government service affiliation

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

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

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

    Code specifying the military service rank

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

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

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

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

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

    Subscriber Eligibility or Benefit Information

    RequiredMax use 1

    To supply eligibility or benefit information

    Usage notes
    • Required when the subscriber is the person whose eligibility or benefits are being described and the transaction is not rejected (see Section 1.4.10) or if the transaction needs to be rejected in this loop. If not required by this implementation guide, do not send.
    • See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what information must be returned if the subscriber is the person whose eligibility or benefits are being sent.
    • Either EB03 or EB13 may be used in the same EB segment, not both.
    • EB03 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110C loop is the same with the exception of the Service Type Code used in EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110C loop are identical.
    • A limit to the number of repeats of EB loops has not been established. In a batch environment there is no practical reason to limit the number of EB loop repeats. In a real time environment, consideration should be given to how many EB loops are generated given the amount of time it takes to format the response and the amount of time it will take to transmit that response. Since these limitations will vary by information source, it would be completely arbitrary for the developers to set a limit. It is not the intent of the developers to limit the amount of information that is returned in a response, rather to alert information sources to consider the potential delays if the response contains too much information to be formatted and transmitted in real time.
    • Use this segment to begin the eligibility/benefit information looping structure. The EB segment is used to convey the specific eligibility or benefit information for the entity identified.
    Example
    If either Quantity Qualifier (EB-09) or Benefit Quantity (EB-10) is present, then the other is required
    EB-01
    1390
    Eligibility or Benefit Information
    Required

    Code identifying eligibility or benefit information

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

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

    B
    Co-Payment

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

    C
    Deductible

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

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

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

    H
    Unlimited
    I
    Non-Covered
    J
    Cost Containment

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

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

    Not recommended. See section 1.4.11 Disclaimers Within the Transaction.

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

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

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

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

    EB-02
    1207
    Benefit Coverage Level Code
    Optional

    Code indicating the level of coverage being provided for this insured

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

    Code identifying the classification of service

    • Position of data in the repeating data element conveys no significance.
    Usage notes
    • See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what service type codes must be returned.
    • EB03 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110C loop is the same with the exception of the Service Type Code used in EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110C loop are identical.
    • Not used if EB13 is present.
    1
    Medical Care
    2
    Surgical
    3
    Consultation
    4
    Diagnostic X-Ray
    5
    Diagnostic Lab
    6
    Radiation Therapy
    7
    Anesthesia
    8
    Surgical Assistance
    9
    Other Medical
    10
    Blood Charges
    11
    Used Durable Medical Equipment
    12
    Durable Medical Equipment Purchase
    13
    Ambulatory Service Center Facility
    14
    Renal Supplies in the Home
    15
    Alternate Method Dialysis
    16
    Chronic Renal Disease (CRD) Equipment
    17
    Pre-Admission Testing
    18
    Durable Medical Equipment Rental
    19
    Pneumonia Vaccine
    20
    Second Surgical Opinion
    21
    Third Surgical Opinion
    22
    Social Work
    23
    Diagnostic Dental
    24
    Periodontics
    25
    Restorative
    26
    Endodontics
    27
    Maxillofacial Prosthetics
    28
    Adjunctive Dental Services
    30
    Health Benefit Plan Coverage

    See Section 1.4.7.1

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

    Use for Routine Vision Exam only.

    AO
    Lenses
    AQ
    Nonmedically Necessary Physical
    AR
    Experimental Drug Therapy
    B1
    Burn Care
    B2
    Brand Name Prescription Drug - Formulary
    B3
    Brand Name Prescription Drug - Non-Formulary
    BA
    Independent Medical Evaluation
    BB
    Partial Hospitalization (Psychiatric)
    BC
    Day Care (Psychiatric)
    BD
    Cognitive Therapy
    BE
    Massage Therapy
    BF
    Pulmonary Rehabilitation
    BG
    Cardiac Rehabilitation
    BH
    Pediatric
    BI
    Nursery
    BJ
    Skin
    BK
    Orthopedic
    BL
    Cardiac
    BM
    Lymphatic
    BN
    Gastrointestinal
    BP
    Endocrine
    BQ
    Neurology
    BR
    Eye
    BS
    Invasive Procedures
    BT
    Gynecological
    BU
    Obstetrical
    BV
    Obstetrical/Gynecological
    BW
    Mail Order Prescription Drug: Brand Name
    BX
    Mail Order Prescription Drug: Generic
    BY
    Physician Visit - Office: Sick
    BZ
    Physician Visit - Office: Well
    C1
    Coronary Care
    CA
    Private Duty Nursing - Inpatient
    CB
    Private Duty Nursing - Home
    CC
    Surgical Benefits - Professional (Physician)
    CD
    Surgical Benefits - Facility
    CE
    Mental Health Provider - Inpatient
    CF
    Mental Health Provider - Outpatient
    CG
    Mental Health Facility - Inpatient
    CH
    Mental Health Facility - Outpatient
    CI
    Substance Abuse Facility - Inpatient
    CJ
    Substance Abuse Facility - Outpatient
    CK
    Screening X-ray
    CL
    Screening laboratory
    CM
    Mammogram, High Risk Patient
    CN
    Mammogram, Low Risk Patient
    CO
    Flu Vaccination
    CP
    Eyewear and Eyewear Accessories
    CQ
    Case Management
    DG
    Dermatology
    DM
    Durable Medical Equipment
    DS
    Diabetic Supplies
    GF
    Generic Prescription Drug - Formulary
    GN
    Generic Prescription Drug - Non-Formulary
    GY
    Allergy
    IC
    Intensive Care
    MH
    Mental Health
    NI
    Neonatal Intensive Care
    ON
    Oncology
    PT
    Physical Therapy
    PU
    Pulmonary
    RN
    Renal
    RT
    Residential Psychiatric Treatment
    TC
    Transitional Care
    TN
    Transitional Nursery Care
    UC
    Urgent Care
    EB-04
    1336
    Insurance Type Code
    Optional

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

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

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

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

    A description or number that identifies the plan or coverage

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

    Code defining periods

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

    Monetary amount

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

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

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

    Code specifying the type of quantity

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

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

    S8
    Age, Low Value

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

    VS
    Visits
    YY
    Years
    EB-10
    380
    Benefit Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

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

    Code indicating a Yes or No condition or response

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

    Code indicating a Yes or No condition or response

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

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

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

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

    C003-01
    235
    Product or Service ID Qualifier
    Required

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

    • C003-01 qualifies C003-02 and C003-08.
    Usage notes
    • Use this code to identify the external code list of the following procedure/service code.
    AD
    American Dental Association Codes
    CJ
    Current Procedural Terminology (CPT) Codes
    HC
    Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
    ID
    International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
    IV
    Home Infusion EDI Coalition (HIEC) Product/Service Code

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

    N4
    National Drug Code in 5-4-2 Format
    ZZ
    Mutually Defined

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

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

    C003-02
    234
    Procedure Code
    Required
    Min 1Max 48

    Identifying number for a product or service

    • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
    Usage notes
    • Use this ID number for the product/service code as qualified by the preceding data element.
    C003-03
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-03 modifies the value in C003-02 and C003-08.
    Usage notes
    • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
    C003-04
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-04 modifies the value in C003-02 and C003-08.
    Usage notes
    • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
    C003-05
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-05 modifies the value in C003-02 and C003-08.
    Usage notes
    • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
    C003-06
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-06 modifies the value in C003-02 and C003-08.
    Usage notes
    • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
    C003-08
    234
    Product or Service ID
    Optional
    Min 1Max 48

    Identifying number for a product or service

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

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

    C004-01
    1328
    Diagnosis Code Pointer
    Required
    Min 1Max 2

    A pointer to the diagnosis code in the order of importance to this service

    • C004-01 identifies the primary diagnosis code for this service line.
    Usage notes
    • This first pointer designates the primary diagnosis for this EB segment. Remaining diagnosis pointers indicate declining level of importance to the EB segment. Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.
    C004-02
    1328
    Diagnosis Code Pointer
    Optional
    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
    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
    Min 1Max 2

    A pointer to the diagnosis code in the order of importance to this service

    • C004-04 identifies the fourth diagnosis code for this service line.
    Usage notes
    • Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.
    HSD
    1350

    Health Care Services Delivery

    OptionalMax use 9

    To specify the delivery pattern of health care services

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

    Code specifying the type of quantity

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

    Numeric value of quantity

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

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

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

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

    HSD-05
    615
    Time Period Qualifier
    Optional

    Code defining periods

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

    Total number of periods

    HSD-07
    678
    Delivery Frequency Code
    Optional

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

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

    Code which specifies the time for routine shipments or deliveries

    A
    1st Shift (Normal Working Hours)
    B
    2nd Shift
    C
    3rd Shift
    D
    A.M.
    E
    P.M.
    F
    As Directed
    G
    Any Shift
    Y
    None (Also Used to Cancel or Override a Previous Pattern)
    REF
    1400

    Subscriber Additional Identification

    OptionalMax use 9

    To specify identifying information

    Usage notes
    • Use this segment for reference identifiers related only to the 2110C loop that it is contained in (e.g. Other or Additional Payer's identifiers).
    • Required when the Information Source requires one or more of these additional identifiers for subsequent EDI transactions (see Section 1.4.7);
      OR
      Required when an additional identifier is associated with the eligibility or benefits being identified in the 2110C loop. If not required by this implementation guide, do not send.
    • Use this segment to identify other or additional reference numbers for the entity identified. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2110C loop.
    Example
    At least one of Subscriber Eligibility or Benefit Identifier (REF-02) or Plan, Group or Plan Network Name (REF-03) is required
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

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

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

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

    ALS
    Alternative List ID

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

    CLI
    Coverage List ID

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

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

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

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

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

    DTP
    1500

    Subscriber Eligibility/Benefit Date

    OptionalMax use 20

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

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

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

    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    096
    Discharge
    193
    Period Start
    194
    Period End
    198
    Completion
    290
    Coordination of Benefits
    291
    Plan

    Use code 291 only if multiple plans apply to the individual or multiple plan periods apply. Dates supplied in this DTP segment only apply to the 2110C loop in which it occurs.

    292
    Benefit
    295
    Primary Care Provider
    304
    Latest Visit or Consultation
    307
    Eligibility
    318
    Added
    346
    Plan Begin

    Use code 346 only if multiple plans apply to the individual or multiple plan periods apply. Dates supplied in this DTP segment only apply to the 2110C loop in which it occurs.

    348
    Benefit Begin
    349
    Benefit End
    356
    Eligibility Begin
    357
    Eligibility End
    435
    Admission
    472
    Service
    636
    Date of Last Update
    771
    Status
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

    • DTP02 is the date or time or period format that will appear in DTP03.
    Usage notes
    • Use this code to specify the format of the date(s)/time(s) that follow in the next data element.
    D8
    Date Expressed in Format CCYYMMDD
    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
    DTP-03
    1251
    Eligibility or Benefit Date Time Period
    Required
    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.
    AAA
    1600

    Subscriber Request Validation

    OptionalMax use 9

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

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

    Code indicating a Yes or No condition or response

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

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

    Y
    Yes

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

    AAA-03
    901
    Reject Reason Code
    Required

    Code assigned by issuer to identify reason for rejection

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

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

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

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

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

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

    AO
    Additional Patient Condition Information Required

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

    CI
    Certification Information Does Not Match Patient

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

    E8
    Requires Medical Review
    IA
    Invalid Authorization Number Format

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

    MA
    Missing Authorization Number

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

    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

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

    Message Text

    OptionalMax use 10

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

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

    Free-form message text

    2115C Subscriber Eligibility or Benefit Additional Information Loop
    OptionalMax 10
    III
    2600

    Subscriber Eligibility or Benefit Additional Information

    RequiredMax use 1

    To report information

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

    Code identifying a specific industry code list

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

    Other code source as specified by the jurisdiction.

    ZZ
    Mutually Defined

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

    III-02
    1271
    Industry Code
    Optional
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

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

    • If III01 is ZZ, use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below, however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here.

      01 Pharmacy
      03 School
      04 Homeless Shelter
      05 Indian Health Service Free-standing Facility
      06 Indian Health Service Provider-based Facility
      07 Tribal 638 Free-standing Facility
      08 Tribal 638 Provider-based Facility
      11 Office
      12 Home
      13 Assisted Living Facility
      14 Group Home
      15 Mobile Unit
      20 Urgent Care Facility
      21 Inpatient Hospital
      22 Outpatient Hospital
      23 Emergency Room - Hospital
      24 Ambulatory Surgical Center
      25 Birthing Center
      26 Military Treatment Facility
      31 Skilled Nursing Facility
      32 Nursing Facility
      33 Custodial Care Facility
      34 Hospice
      41 Ambulance - Land
      42 Ambulance - Air or Water
      49 Independent Clinic
      50 Federally Qualified Health Center
      51 Inpatient Psychiatric Facility
      52 Psychiatric Facility - Partial Hospitalization
      53 Community Mental Health Center
      54 Intermediate Care Facility/Mentally Retarded
      55 Residential Substance Abuse Treatment Facility
      56 Psychiatric Residential Treatment Center
      57 Non-residential Substance Abuse Treatment Facility
      60 Mass Immunization Center
      61 Comprehensive Inpatient Rehabilitation Facility
      62 Comprehensive Outpatient Rehabilitation Facility
      65 End-Stage Renal Disease Treatment Facility
      71 State or Local Public Health Clinic
      72 Rural Health Clinic
      81 Independent Laboratory
      99 Other Place of Service

    III-03
    1136
    Code Category
    Optional

    Specifies the situation or category to which the code applies

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

    Free-form message text

    Usage notes
    • Use this element to describe the injured body part or parts.
    LS
    3300

    Loop Header

    OptionalMax use 1

    To indicate that the next segment begins a loop

    Example
    LS-01
    447
    Loop Identifier Code
    Required
    Min 1Max 6

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

    2120C Subscriber Benefit Related Entity Name Loop
    OptionalMax 23
    NM1
    3400

    Subscriber Benefit Related Entity Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    1I
    Preferred Provider Organization (PPO)

    Use if identifying a Preferred Provider Organization (PPO) by name or identification number. May also be used if identifying the Network that benefits are restricted to when 2110C EB12 = "Y" (In-Network).

    1P
    Provider
    2B
    Third-Party Administrator
    13
    Contracted Service Provider
    36
    Employer
    73
    Other Physician
    FA
    Facility
    GP
    Gateway Provider
    GW
    Group
    I3
    Independent Physicians Association (IPA)
    IL
    Insured or Subscriber

    Use if identifying an insured or subscriber to a plan other than the information source (such as in a co-ordination of benefits situation).

    LR
    Legal Representative
    OC
    Origin Carrier

    Use if identifying an organization that added information relating to other insurance.

    P3
    Primary Care Provider
    P4
    Prior Insurance Carrier
    P5
    Plan Sponsor
    PR
    Payer
    PRP
    Primary Payer
    SEP
    Secondary Payer
    TTP
    Tertiary Payer
    VER
    Party Performing Verification

    Use this code when identifying the true Information Source and no other code is appropriate. See Section 1.4.7.1 271 item 11 for additional information.

    VN
    Vendor
    VY
    Organization Completing Configuration Change

    Use if identifying an organization that changed information relating to other insurance.

    X3
    Utilization Management Organization
    Y2
    Managed Care Organization
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

    NM1-05
    1037
    Benefit Related Entity Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Benefit Related Entity Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

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

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

    Usage notes
    • Use code value "XX" if the entity is a provider and the National Provider ID is mandated for use.
      Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
      If the entity being identified is an individual, the "HIPAA Individual Identifier" must be used once this identifier has been adopted.
      Otherwise use appropriate code value for the entity.
    24
    Employer's Identification Number
    34
    Social Security Number

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

    46
    Electronic Transmitter Identification Number (ETIN)
    FA
    Facility Identification
    FI
    Federal Taxpayer's Identification Number
    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

    Use this code to identify the entity's Member Identification Number associated with a payer other than the information source in Loop 2100A. This code may only be used prior to the mandated use of code "II".

    NI
    National Association of Insurance Commissioners (NAIC) Identification
    PI
    Payor Identification
    PP
    Pharmacy Processor Number
    SV
    Service Provider Number
    XV
    Centers for Medicare and Medicaid Services PlanID
    XX
    Centers for Medicare and Medicaid Services National Provider Identifier
    NM1-09
    67
    Benefit Related Entity Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    Usage notes
    • Use this code for the reference number as qualified by the preceding data element (NM108).
    NM1-10
    706
    Benefit Related Entity Relationship Code
    Optional

    Code describing entity relationship

    • NM110 and NM111 further define the type of entity in NM101.
    01
    Parent
    02
    Child
    27
    Domestic Partner
    41
    Spouse
    48
    Employee
    65
    Other
    72
    Unknown
    N3
    3600

    Subscriber Benefit Related Entity Address

    OptionalMax use 1

    To specify the location of the named party

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

    Address information

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

    Address information

    Usage notes
    • Use this information for the second line of the address information.
    N4
    3700

    Subscriber Benefit Related Entity City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

    Code (Standard State/Province) as defined by appropriate government agency

    • N402 is required only if city name (N401) is in the U.S. or Canada.
    N4-03
    116
    Benefit Related Entity Postal Zone or ZIP Code
    Optional
    Min 3Max 15

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

    N4-04
    26
    Benefit Related Entity Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying type of location

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

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

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

    Code which identifies a specific location

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    PER
    3800

    Subscriber Benefit Related Entity Contact Information

    OptionalMax use 3

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

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

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

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

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

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

    Free-form name

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

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

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

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

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

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    Usage notes
    • The format for US domestic phone numbers is:
      AAABBBCCCC
      AAA = Area Code
      BBBCCCC = Local Number
    • Use this for the communication number or URL as qualified by the preceding data element.
    PRV
    3900

    Subscriber Benefit Related Provider Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

    Usage notes
    • Required when needed either to identify a provider's role or associate a specialty type related to the service identified in the 2110C loop. If not required by this implementation guide, do not send.
    • If identifying a type of specialty associated with the services identified in loop 2110C, use code PXC in PRV02 and the appropriate code in PRV03.
    • If there is a PRV segment in 2100B or 2100C, this PRV overrides it for this occurrence of the 2110C loop.
    Example
    If either Reference Identification Qualifier (PRV-02) or Benefit Related Entity Provider Taxonomy Code (PRV-03) is present, then the other is required
    PRV-01
    1221
    Provider Code
    Required

    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

    Code qualifying the Reference Identification

    PXC
    Health Care Provider Taxonomy Code
    PRV-03
    127
    Benefit Related Entity Provider Taxonomy Code
    Optional
    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).
    LE
    4000

    Loop Trailer

    OptionalMax use 1

    To indicate that the loop immediately preceding this segment is complete

    Example
    LE-01
    447
    Loop Identifier Code
    Required
    Min 1Max 6

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

    2000D Dependent Level Loop
    OptionalMax >1
    HL
    0100

    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
    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
    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

    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

    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

    Dependent Trace Number

    OptionalMax use 3

    To uniquely identify a transaction to an application

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

    Code identifying which transaction is being referenced

    1
    Current Transaction Trace Numbers

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

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

    2
    Referenced Transaction Trace Numbers

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

    TRN-02
    127
    Trace Number
    Required
    Min 1Max 50

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

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

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

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

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

    • TRN04 identifies a further subdivision within the organization.
    Usage notes
    • If TRN01 is "1", use this information if necessary to further identify a specific component, such as a specific division or group of the entity identified in the previous data element (TRN03).
    • If TRN01 is "2", this is the value received in the original 270 transaction.
    2100D Dependent Name Loop
    RequiredMax 1
    NM1
    0300

    Dependent Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    03
    Dependent
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

    Usage notes
    • Use this name for the dependent's first name.
    NM1-05
    1037
    Dependent Middle Name
    Optional
    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
    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

    Dependent Additional Identification

    OptionalMax use 9

    To specify identifying information

    Usage notes
    • If the 270 request contained a REF segment with a Patient Account Number in Loop 2100D/REF02 with REF01 equal EJ, then it must be returned in the 271 transaction using this segment if the patient is the Dependent. The Patient Account Number in the 271 transaction must be returned exactly as submitted in the 270 transaction.
    • Required when the Information Source requires additional identifiers necessary to identify the Dependent for subsequent EDI transactions (see Section 1.4.7);
      OR
      Required when the 270 request contained a REF segment with a Patient Account Number in Loop 2100D/REF02 with REF01 equal EJ;
      OR
      Required when the 270 request contained a REF segment and the information provided in that REF segment was used to locate the individual in the information source's system (See Section 1.4.7).
      If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
    • Use this segment to supply an identification number other than or in addition to the Member Identification Number. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100D loop.
    • Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Numbers are to be provided in the NM1 segment as a Member Identification Number when it is the primary number an information source knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
    Example
    At least one of Dependent Supplemental Identifier (REF-02) or Plan, Group or Plan Network Name (REF-03) is required
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    1W
    Member Identification Number

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

    6P
    Group Number
    18
    Plan Number
    49
    Family Unit Number

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

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

    CE
    Class of Contract Code

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

    CT
    Contract Number

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

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

    See segment note 3.

    GH
    Identification Card Serial Number

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

    HJ
    Identity Card Number

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

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

    See segment note 3.

    Q4
    Prior Identifier Number

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

    SY
    Social Security Number

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

    Y4
    Agency Claim Number

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

    REF-02
    127
    Dependent Supplemental Identifier
    Required
    Min 1Max 50

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

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

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

    N3
    0600

    Dependent Address

    OptionalMax use 1

    To specify the location of the named party

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

    Address information

    Usage notes
    • Use this information for the second line of the address information.
    N4
    0700

    Dependent City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • Required when the Information Source requires this information to identify the Dependent for subsequent EDI transactions (see Section 1.4.7),
      OR
      Required if a rejection response is generated and this segment was present in the 270 and is the cause of the rejection.
      If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
    • Do not return address information from the 270 request unless the transaction is rejected and the rejection was caused by the address and this segment was present in the 270. See Section 1.4.7.1 271 item 7 for additional information.
    • Use this segment to identify address information for a dependent.
    Example
    Only one of Dependent State Code (N4-02) or Dependent Country Subdivision Code (N4-07) may be present
    If Dependent Country Subdivision Code (N4-07) is present, then Dependent Country Code (N4-04) is required
    N4-01
    19
    Dependent City Name
    Required
    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
    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
    Min 3Max 15

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

    N4-04
    26
    Dependent Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    AAA
    0850

    Dependent Request Validation

    OptionalMax use 9

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

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

    Code indicating a Yes or No condition or response

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

    Code assigned by issuer to identify reason for rejection

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

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

    42
    Unable to Respond at Current Time

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

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

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

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

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

    66
    Invalid/Missing Patient Gender Code
    67
    Patient Not Found

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

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

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

    77
    Subscriber Found, Patient Not Found
    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

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

    Use only when AAA03 is "42".

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

    Use only when AAA03 is "42".

    PRV
    0900

    Provider Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

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

    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

    Code qualifying the Reference Identification

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

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

    Usage notes
    • Use this number for the reference number as qualified by the preceding data element (PRV02).
    DMG
    1000

    Dependent Demographic Information

    OptionalMax use 1

    To supply demographic information

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

    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
    Min 1Max 35

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

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

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    U
    Unknown
    INS
    1100

    Dependent Relationship

    OptionalMax use 1

    To provide benefit information on insured entities

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

    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

    Code indicating the relationship between two individuals or entities

    01
    Spouse
    19
    Child
    20
    Employee
    21
    Unknown

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

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

    Code identifying the specific type of item maintenance

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

    Code identifying the reason for the maintenance change

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

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

    INS-17
    1470
    Birth Sequence Number
    Optional
    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

    Dependent Health Care Diagnosis Code

    OptionalMax use 1

    To supply information related to the delivery of health care

    Usage notes
    • Required when an HI segment was received in the 270 and if the information source uses the information in the determination of the eligibility or benefit response for the dependent. All information used from the HI segment of the 270 used in the determination of the eligibility or benefit response for the dependent must be returned. If information was provided in an HI segment of 270 but was not used in the determination of the eligibility or benefits for the dependent it must not be returned. The information source must not use information in an HI segment of the 270 transaction in the determination of eligibility or benefits for the dependent if that information cannot be returned in the 271 response.
      OR
      Required when needed to identify limitations in the benefits identified in the 2110D loops, such as if benefits are limited for a specific diagnosis code if the information source can support this high level functionality. If the information source cannot support this high level functionality, do not send.
    • Use the Diagnosis code pointers in 2110D EB14 to identify which diagnosis code or codes in this HI segment relates to the information provided in the EB segment.
    • Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
    Example
    HI-01
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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

    Dependent Date

    OptionalMax use 9

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

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

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

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

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

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

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

    • DTP02 is the date or time or period format that will appear in DTP03.
    Usage notes
    • Use this code to specify the format of the date(s)/time(s) that follow in the next data element.
    D8
    Date Expressed in Format CCYYMMDD
    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
    DTP-03
    1251
    Date Time Period
    Required
    Min 1Max 35

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

    Usage notes
    • Use this date for the date(s) as qualified by the preceding data elements.
    MPI
    1275

    Dependent Military Personnel Information

    OptionalMax use 1

    To report military service data

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

    A code to indicate the status of information

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

    Code showing the general employment status of an employee/claimant

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

    Code specifying the government service affiliation

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

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

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

    Code specifying the military service rank

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

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

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

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

    • MPI07 indicates the date span of military service.
    2110D Dependent Eligibility or Benefit Information Loop
    OptionalMax >1
    EB
    1300

    Dependent Eligibility or Benefit Information

    RequiredMax use 1

    To supply eligibility or benefit information

    Usage notes
    • See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what information must be returned if the subscriber is the person whose eligibility or benefits are being sent.
    • Either EB03 or EB13 may be used in the same EB segment, not both.
    • Required when the dependent is the person whose eligibility or benefits are being described and the transaction is not rejected (see Section 1.4.10) or if the transaction needs to be rejected in this loop. If not required by this implementation guide, do not send.
    • EB03 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110D loop is the same with the exception of the Service Type Code used in EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110D loop are identical.
    • A limit to the number of repeats of EB loops has not been established. In a batch environment there is no practical reason to limit the number of EB loop repeats. In a real time environment, consideration should be given to how many EB loops are generated given the amount of time it takes to format the response and the amount of time it will take to transmit that response. Since these limitations will vary by information source, it would be completely arbitrary for the developers to set a limit. It is not the intent of the developers to limit the amount of information that is returned in a response, rather to alert information sources to consider the potential delays if the response contains too much information to be formatted and transmitted in real time.
    • Use this segment to begin the eligibility/benefit information looping structure. The EB segment is used to convey the specific eligibility or benefit information for the entity identified.
    Example
    If either Quantity Qualifier (EB-09) or Benefit Quantity (EB-10) is present, then the other is required
    EB-01
    1390
    Eligibility or Benefit Information
    Required

    Code identifying eligibility or benefit information

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

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

    B
    Co-Payment

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

    C
    Deductible

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

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

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

    H
    Unlimited
    I
    Non-Covered
    J
    Cost Containment

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

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

    Not recommended. See section 1.4.11 Disclaimers Within the Transaction.

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

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

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

    See Section 1.4.9 Patient Responsibility for detailed information and definitions.

    EB-02
    1207
    Benefit Coverage Level Code
    Optional

    Code indicating the level of coverage being provided for this insured

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

    Code identifying the classification of service

    • Position of data in the repeating data element conveys no significance.
    Usage notes
    • See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what service type codes must be returned.
    • EB03 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110D loop is the same with the exception of the Service Type Code used in EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110D loop are identical.
    • Not used if EB13 is present.
    1
    Medical Care
    2
    Surgical
    3
    Consultation
    4
    Diagnostic X-Ray
    5
    Diagnostic Lab
    6
    Radiation Therapy
    7
    Anesthesia
    8
    Surgical Assistance
    9
    Other Medical
    10
    Blood Charges
    11
    Used Durable Medical Equipment
    12
    Durable Medical Equipment Purchase
    13
    Ambulatory Service Center Facility
    14
    Renal Supplies in the Home
    15
    Alternate Method Dialysis
    16
    Chronic Renal Disease (CRD) Equipment
    17
    Pre-Admission Testing
    18
    Durable Medical Equipment Rental
    19
    Pneumonia Vaccine
    20
    Second Surgical Opinion
    21
    Third Surgical Opinion
    22
    Social Work
    23
    Diagnostic Dental
    24
    Periodontics
    25
    Restorative
    26
    Endodontics
    27
    Maxillofacial Prosthetics
    28
    Adjunctive Dental Services
    30
    Health Benefit Plan Coverage

    See Section 1.4.7.1

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

    Use for Routine Vision Exam only.

    AO
    Lenses
    AQ
    Nonmedically Necessary Physical
    AR
    Experimental Drug Therapy
    B1
    Burn Care
    B2
    Brand Name Prescription Drug - Formulary
    B3
    Brand Name Prescription Drug - Non-Formulary
    BA
    Independent Medical Evaluation
    BB
    Partial Hospitalization (Psychiatric)
    BC
    Day Care (Psychiatric)
    BD
    Cognitive Therapy
    BE
    Massage Therapy
    BF
    Pulmonary Rehabilitation
    BG
    Cardiac Rehabilitation
    BH
    Pediatric
    BI
    Nursery
    BJ
    Skin
    BK
    Orthopedic
    BL
    Cardiac
    BM
    Lymphatic
    BN
    Gastrointestinal
    BP
    Endocrine
    BQ
    Neurology
    BR
    Eye
    BS
    Invasive Procedures
    BT
    Gynecological
    BU
    Obstetrical
    BV
    Obstetrical/Gynecological
    BW
    Mail Order Prescription Drug: Brand Name
    BX
    Mail Order Prescription Drug: Generic
    BY
    Physician Visit - Office: Sick
    BZ
    Physician Visit - Office: Well
    C1
    Coronary Care
    CA
    Private Duty Nursing - Inpatient
    CB
    Private Duty Nursing - Home
    CC
    Surgical Benefits - Professional (Physician)
    CD
    Surgical Benefits - Facility
    CE
    Mental Health Provider - Inpatient
    CF
    Mental Health Provider - Outpatient
    CG
    Mental Health Facility - Inpatient
    CH
    Mental Health Facility - Outpatient
    CI
    Substance Abuse Facility - Inpatient
    CJ
    Substance Abuse Facility - Outpatient
    CK
    Screening X-ray
    CL
    Screening laboratory
    CM
    Mammogram, High Risk Patient
    CN
    Mammogram, Low Risk Patient
    CO
    Flu Vaccination
    CP
    Eyewear and Eyewear Accessories
    CQ
    Case Management
    DG
    Dermatology
    DM
    Durable Medical Equipment
    DS
    Diabetic Supplies
    GF
    Generic Prescription Drug - Formulary
    GN
    Generic Prescription Drug - Non-Formulary
    GY
    Allergy
    IC
    Intensive Care
    MH
    Mental Health
    NI
    Neonatal Intensive Care
    ON
    Oncology
    PT
    Physical Therapy
    PU
    Pulmonary
    RN
    Renal
    RT
    Residential Psychiatric Treatment
    TC
    Transitional Care
    TN
    Transitional Nursery Care
    UC
    Urgent Care
    EB-04
    1336
    Insurance Type Code
    Optional

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

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

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

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

    A description or number that identifies the plan or coverage

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

    Code defining periods

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

    Monetary amount

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

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

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

    Code specifying the type of quantity

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

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

    S8
    Age, Low Value

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

    VS
    Visits
    YY
    Years
    EB-10
    380
    Benefit Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

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

    Code indicating a Yes or No condition or response

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

    Code indicating a Yes or No condition or response

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

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

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

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

    C003-01
    235
    Product or Service ID Qualifier
    Required

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

    • C003-01 qualifies C003-02 and C003-08.
    Usage notes
    • Use this code to identify the external code list of the following procedure/service code.
    AD
    American Dental Association Codes
    CJ
    Current Procedural Terminology (CPT) Codes
    HC
    Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
    ID
    International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
    IV
    Home Infusion EDI Coalition (HIEC) Product/Service Code

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

    N4
    National Drug Code in 5-4-2 Format
    ZZ
    Mutually Defined

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

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

    C003-02
    234
    Procedure Code
    Required
    Min 1Max 48

    Identifying number for a product or service

    • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
    Usage notes
    • Use this ID number for the product/service code as qualified by the preceding data element.
    C003-03
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-03 modifies the value in C003-02 and C003-08.
    Usage notes
    • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
    C003-04
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-04 modifies the value in C003-02 and C003-08.
    Usage notes
    • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
    C003-05
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-05 modifies the value in C003-02 and C003-08.
    Usage notes
    • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
    C003-06
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-06 modifies the value in C003-02 and C003-08.
    Usage notes
    • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
    C003-08
    234
    Product or Service ID
    Optional
    Min 1Max 48

    Identifying number for a product or service

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

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

    C004-01
    1328
    Diagnosis Code Pointer
    Required
    Min 1Max 2

    A pointer to the diagnosis code in the order of importance to this service

    • C004-01 identifies the primary diagnosis code for this service line.
    Usage notes
    • This first pointer designates the primary diagnosis for this EB segment. Remaining diagnosis pointers indicate declining level of importance to the EB segment. Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.
    C004-02
    1328
    Diagnosis Code Pointer
    Optional
    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
    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
    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.
    HSD
    1350

    Health Care Services Delivery

    OptionalMax use 9

    To specify the delivery pattern of health care services

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

    Code specifying the type of quantity

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

    Numeric value of quantity

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

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

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

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

    HSD-05
    615
    Time Period Qualifier
    Optional

    Code defining periods

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

    Total number of periods

    HSD-07
    678
    Delivery Frequency Code
    Optional

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

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

    Code which specifies the time for routine shipments or deliveries

    A
    1st Shift (Normal Working Hours)
    B
    2nd Shift
    C
    3rd Shift
    D
    A.M.
    E
    P.M.
    F
    As Directed
    G
    Any Shift
    Y
    None (Also Used to Cancel or Override a Previous Pattern)
    REF
    1400

    Dependent Additional Identification

    OptionalMax use 9

    To specify identifying information

    Usage notes
    • Use this segment for reference identifiers related only to the 2110D loop that it is contained in (e.g. Other or Additional Payer's identifiers).
    • Required when the Information Source requires one or more of these additional identifiers for subsequent EDI transactions (see Section 1.4.7);
      OR
      Required when an additional identifier is associated with the eligibility or benefits being identified in the 2110D loop.
      If not required by this implementation guide, do not send.
    • Use this segment to identify other or additional reference numbers for the entity identified. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2110D loop.
    Example
    At least one of Dependent Eligibility or Benefit Identifier (REF-02) or Plan, Group or Plan Network Name (REF-03) is required
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

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

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

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

    ALS
    Alternative List ID

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

    CLI
    Coverage List ID

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

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

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

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

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

    DTP
    1500

    Dependent Eligibility/Benefit Date

    OptionalMax use 20

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

    Usage notes
    • When using the DTP segment in the 2110D loop this date applies only to the 2110D Eligibility or Benefit Information (EB) loop in which it is located.

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

    • Required when the individual has active coverage with multiple plans or multiple plan periods apply (See 2100D DTP segment);
      OR
      Required when needed to convey dates associated with the eligibility or benefits being identified in the 2110D loop.
      If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    096
    Discharge
    193
    Period Start
    194
    Period End
    198
    Completion
    290
    Coordination of Benefits
    291
    Plan

    Use code 291 only if multiple plans apply to the individual or multiple plan periods apply. Dates supplied in this DTP segment only apply to the 2110D loop in which it occurs.

    292
    Benefit
    295
    Primary Care Provider
    304
    Latest Visit or Consultation
    307
    Eligibility
    318
    Added
    346