X12 271 Health Care Eligibility Benefit Response (X279A1)
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.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HB
- Eligibility, Coverage or Benefit Information (271)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X279A1
- 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
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
- Use this control segment to mark the start of a transaction set. One ST segment exists for every transaction set that occurs within a functional group.
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- Use this code to identify the transaction set ID for the transaction set that will follow the ST segment. Each X12 standard has a transaction set identifier code that is unique to that transaction set.
- 271
- Eligibility, Coverage or Benefit Information
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example "0001", and increment from there.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with 005010X279A1.
- This element contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST/SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
- 005010X279A1
Beginning of Hierarchical Transaction
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
- Use this required segment to start the transaction set and indicate the sequence of the hierarchical levels of information that will follow in Table 2.
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- Use this code to specify the sequence of hierarchical levels that may appear in the transaction set. This code only indicates the sequence of the levels, not the requirement that all levels be present. For example, if code "0022" is used, the dependent level may or may not be present for each subscriber.
- 0022
- Information Source, Information Receiver, Subscriber, Dependent
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
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.
- 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.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
- Use this date for the date the transaction set was generated.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
- Use this time for the time the transaction set was generated.
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Request Validation
To specify the validity of the request and indicate follow-up action authorized
- 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.
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.
Code assigned by issuer to identify reason for rejection
- 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.
Code identifying follow-up actions allowed
- 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
Information Source Name
To supply the full name of an individual or organizational entity
- 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).
Code identifying an organizational entity, a physical location, property or an individual
- 2B
- Third-Party Administrator
- 36
- Employer
- GP
- Gateway Provider
- P5
- Plan Sponsor
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- Use this code to indicate whether the entity is an individual person or an organization.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
- Use this name for the organization name if NM102 is "2". Otherwise, this will be the individual's last name.
Code designating the system/method of code structure used for Identification Code (67)
- Use this element to qualify the identification number submitted in NM109. This is the number that the information source associates with the information receiver. Because only one number can be submitted in NM109, the following hierarchy must be used. Additional identifiers are to be placed in the REF segment. If the information receiver is a provider and the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate, code value "XX" must be used. Otherwise, one of the following codes may be used with the following hierarchy applied: Use the first code that applies: "SV", "PP", "FI", "34". The code "SV" is recommended to be used prior to the mandated use of the National Provider ID.
Use "PI" when Information Receiver is a payer and "XV" is not used.
Use "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
If the information receiver is an employer, use code value "24".
- 24
- Employer's Identification Number
- 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
Code identifying a party or other code
Information Source Contact Information
To identify a person or office to whom administrative communications should be directed
- 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.
Code identifying the major duty or responsibility of the person or group named
- Use this code to specify the type of person or group to which the contact number applies.
- IC
- Information Contact
Free-form name
- 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).
Code identifying the type of communication number
- 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)
Complete communications number including country or area code when applicable
- 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
Code identifying the type of communication number
- 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)
Complete communications number including country or area code when applicable
- 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.
Code identifying the type of communication number
- 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)
Complete communications number including country or area code when applicable
- 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.
Request Validation
To specify the validity of the request and indicate follow-up action authorized
- 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.
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.
Code assigned by issuer to identify reason for rejection
- 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.
Code identifying follow-up actions allowed
- 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
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 21
- Information Receiver
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Receiver Name
To supply the full name of an individual or organizational entity
- Use this segment to identify an entity by name and/or identification number. This NM1 loop is used to identify the eligibility/benefit information receiver (e.g., provider, medical group, IPA, or hospital).
Code identifying an organizational entity, a physical location, property or an individual
- 1P
- Provider
- 2B
- Third-Party Administrator
- 36
- Employer
- 80
- Hospital
- FA
- Facility
- GP
- Gateway Provider
- P5
- Plan Sponsor
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- Use this code to indicate whether the entity is an individual person or an organization.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
- 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.
Individual first name
- Use this name only if NM102 is "1".
Individual middle name or initial
- Use this name only if NM102 is "1".
Suffix to individual name
- Use name suffix only if NM102 is "1"; e.g., Sr., Jr., or III.
Code designating the system/method of code structure used for Identification Code (67)
- Use this element to qualify the identification number submitted in NM109. This is the 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
Code identifying a party or other code
Information Receiver Additional Identification
To specify identifying information
- Use this segment when needed to convey other or additional identification numbers for the information receiver. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100B loop.
- Required when 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.
Code qualifying the Reference Identification
- 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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this information for the reference number as qualified by the preceding data element (REF01).;
A free-form description to clarify the related data elements and their content
- 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.
Information Receiver Address
To specify the location of the named party
- 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.
Information Receiver City, State, ZIP Code
To specify the geographic place of the named party
- 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.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Information Receiver Request Validation
To specify the validity of the request and indicate follow-up action authorized
- 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.
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.
Code assigned by issuer to identify reason for rejection
- 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.
Code identifying follow-up actions allowed
- 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
Information Receiver Provider Information
To specify the identifying characteristics of a provider
- 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.
Code identifying the type of provider
- AD
- Admitting
- AT
- Attending
- BI
- Billing
- CO
- Consulting
- CV
- Covering
- H
- Hospital
- HH
- Home Health Care
- LA
- Laboratory
- OT
- Other Physician
- P1
- Pharmacist
- P2
- Pharmacy
- PC
- Primary Care Physician
- PE
- Performing
- R
- Rural Health Clinic
- RF
- Referring
- SB
- Submitting
- SK
- Skilled Nursing Facility
- SU
- Supervising
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this number for the reference number as qualified by the preceding data element (PRV02).
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 22
- Subscriber
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Subscriber Trace Number
To uniquely identify a transaction to an application
- 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.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- This element must contain the trace number submitted in TRN02 from the 270 transaction and must be returned exactly as submitted.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- 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.
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.
Subscriber Name
To supply the full name of an individual or organizational entity
- Use this segment to identify an entity by name and/or identification number. This NM1 loop is used to identify the insured or subscriber.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
- Use this name for the subscriber's last name.
Individual first name
- Use this name for the subscriber's first name.
Individual middle name or initial
- Use this name for the subscriber's middle name or initial.
Suffix to individual name
- Use this for the suffix to an individual's name; e.g., Sr., Jr., or III.
Code designating the system/method of code structure used for Identification Code (67)
- Use this element to qualify the identification number submitted in;NM109. This is the primary number that the information source;associates with the subscriber.
- 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.).
Code identifying a party or other code
- Use this code for the reference number as qualified by the preceding data element (NM108).
Subscriber Additional Identification
To specify identifying information
- 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.
Code qualifying the Reference Identification
- 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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- 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.
A free-form description to clarify the related data elements and their content
Subscriber Address
To specify the location of the named party
- 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.
Address information
- Use this information for the first line of the address information.
Address information
- Use this information for the second line of the address information.
Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the 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.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Subscriber Request Validation
To specify the validity of the request and indicate follow-up action authorized
- 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).
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.
Code assigned by issuer to identify reason for rejection
- 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
Code identifying follow-up actions allowed
- 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".
Provider Information
To specify the identifying characteristics of a provider
- 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.
Code identifying the type of provider
- AD
- Admitting
- AT
- Attending
- BI
- Billing
- CO
- Consulting
- CV
- Covering
- H
- Hospital
- HH
- Home Health Care
- LA
- Laboratory
- OT
- Other Physician
- P1
- Pharmacist
- P2
- Pharmacy
- PC
- Primary Care Physician
- PE
- Performing
- R
- Rural Health Clinic
- RF
- Referring
- SK
- Skilled Nursing Facility
- SU
- Supervising
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this number for the reference number as qualified by the preceding data element (PRV02).
Subscriber Demographic Information
To supply demographic information
- 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.
Code indicating the date format, time format, or date and time format
- Use this code to indicate the format of the date of birth that follows in DMG02.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
- Use this date for the date of birth of the subscriber.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Subscriber Relationship
To provide benefit information on insured entities
- 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.
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
Code indicating the relationship between two individuals or entities
- 18
- Self
Code identifying the specific type of item maintenance
- 001
- Change
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.
A generic number
- INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
- Use to indicate the birth order in the event of multiple birth's in association with the birth date supplied in DMG02.
Subscriber Health Care Diagnosis Code
To supply information related to the delivery of health care
- 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.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
- BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data element has been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Subscriber Date
To specify any or all of a date, a time, or a time period
- 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.
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
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- Use this code to specify the format of the date(s)/time(s) that follow in the next data element.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- Use this date for the date(s) as qualified by the preceding data elements.
Subscriber Military Personnel Information
To report military service data
- 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.
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
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
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
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.
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
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
Expression of a date, a time, or range of dates, times or dates and times
- MPI07 indicates the date span of military service.
Subscriber Eligibility or Benefit Information
To supply eligibility or benefit information
- 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.
Code identifying eligibility or benefit information
- EB01 qualifies EB06 through EB10.
- 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.
Code indicating the level of coverage being provided for this insured
- 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
Code identifying the classification of service
- Position of data in the repeating data element conveys no significance.
- 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
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
A description or number that identifies the plan or coverage
- 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.
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
Monetary amount
- 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.
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)
- 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.
Code specifying the type of quantity
- 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
Numeric value of quantity
- Use this number for the quantity value as qualified by the preceding data element (EB09).
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.
- 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
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.
- 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
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.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- Use this code to 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)
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- Use this ID number for the product/service code as qualified by the preceding data element.
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.
- Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
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.
- Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
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.
- Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
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.
- Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
- 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.
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.
A pointer to the diagnosis code in the order of importance to this service
- C004-01 identifies the primary diagnosis code for this service line.
- This first pointer designates the primary diagnosis for this 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.
A pointer to the diagnosis code in the order of importance to this service
- C004-02 identifies the second diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.
A pointer to the diagnosis code in the order of importance to this service
- C004-03 identifies the third diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.
A pointer to the diagnosis code in the order of importance to this service
- C004-04 identifies the fourth diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.
Health Care Services Delivery
To specify the delivery pattern of health care services
- 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.
Code specifying the type of quantity
- Required if HSD02 is used.
- DY
- Days
- FL
- Units
- HS
- Hours
- MN
- Month
- VS
- Visits
Numeric value of quantity
- Required if HSD01 is used.
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
To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes
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
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)
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)
Subscriber Additional Identification
To specify identifying information
- 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.
Code qualifying the Reference Identification
- 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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this information for the reference number as qualified by the preceding data element (REF01).;
A free-form description to clarify the related data elements and their content
Subscriber Eligibility/Benefit Date
To specify any or all of a date, a time, or a time period
- 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.
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
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- Use this code to specify the format of the date(s)/time(s) that follow in the next data element.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- Use this date for the date(s) as qualified by the preceding data elements.
Subscriber Request Validation
To specify the validity of the request and indicate follow-up action authorized
- 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).
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.
Code assigned by issuer to identify reason for rejection
- 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.
Code identifying follow-up actions allowed
- 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
Message Text
To provide a free-form format that allows the transmission of text information
- 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.
Subscriber Eligibility or Benefit Additional Information
To report information
- 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.
Code identifying a specific industry code list
- 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.
Code indicating a code from a specific industry code list
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
Specifies the situation or category to which the code applies
- III03 is used to categorize III04.
- 44
- Nature of Injury
Free-form message text
- Use this element to describe the injured body part or parts.
The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE
Subscriber Benefit Related Entity Name
To supply the full name of an individual or organizational entity
- 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.
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
Code qualifying the type of entity
- NM102 qualifies NM103.
- Use this code to indicate whether the entity is an individual person or an organization.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
- Use this name for the organization name if the entity type qualifier is a non-person entity. Otherwise, this will be the individual's last name.
Suffix to individual name
- Use for name suffix only (e.g. Sr, Jr, II, III, etc.).
Code designating the system/method of code structure used for Identification Code (67)
- 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
Code identifying a party or other code
- Use this code for the reference number as qualified by the preceding data element (NM108).
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
Subscriber Benefit Related Entity Address
To specify the location of the named party
- 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.
Address information
- Use this information for the first line of the address information.
Address information
- Use this information for the second line of the address information.
Subscriber Benefit Related Entity City, State, ZIP Code
To specify the geographic place of the named party
- 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.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying type of location
- 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.
Code which identifies a specific location
- Use this element only to communicate the Department of Defense Health Service Region.
- CODE SOURCE DOD1: Military Health Systems Functional Area Manual - Data.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Subscriber Benefit Related Entity Contact Information
To identify a person or office to whom administrative communications should be directed
- 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.
Code identifying the major duty or responsibility of the person or group named
- Use this code to specify the type of person or group to which the contact number applies.
- IC
- Information Contact
Free-form name
- Use this name for the individual's name or group's name to use when contacting the individual or organization.
Code identifying the type of communication number
- 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
Complete communications number including country or area code when applicable
- 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.
Code identifying the type of communication number
- 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
Complete communications number including country or area code when applicable
- 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.
Code identifying the type of communication number
- 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
Complete communications number including country or area code when applicable
- 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.
Subscriber Benefit Related Provider Information
To specify the identifying characteristics of a provider
- 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.
Code identifying the type of provider
- AD
- Admitting
- AT
- Attending
- BI
- Billing
- CO
- Consulting
- CV
- Covering
- H
- Hospital
- HH
- Home Health Care
- LA
- Laboratory
- OT
- Other Physician
- P1
- Pharmacist
- P2
- Pharmacy
- PC
- Primary Care Physician
- PE
- Performing
- R
- Rural Health Clinic
- RF
- Referring
- SB
- Submitting
- SK
- Skilled Nursing Facility
- SU
- Supervising
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this reference number as qualified by the preceding data element (PRV02).
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 23
- Dependent
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
Dependent Trace Number
To uniquely identify a transaction to an application
- 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.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- This element must contain the trace number submitted in TRN02 from the 270 transaction and must be returned exactly as submitted.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- 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.
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.
- 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.
Dependent Name
To supply the full name of an individual or organizational entity
- Use this segment to identify an entity by name. This NM1 loop is used to identify the dependent of an insured or subscriber.
Code identifying an organizational entity, a physical location, property or an individual
- 03
- Dependent
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
- Use this name for the dependent's last name.
Individual first name
- Use this name for the dependent's first name.
Individual middle name or initial
- Use this name for the dependent's middle name or initial.
Suffix to individual name
- Use this for the suffix to an individual's name; e.g., Sr., Jr., or III.
Dependent Additional Identification
To specify identifying information
- 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.
Code qualifying the Reference Identification
- 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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- 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.
A free-form description to clarify the related data elements and their content
Dependent Address
To specify the location of the named party
- 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.
Dependent City, State, ZIP Code
To specify the geographic place of the named party
- 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.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Dependent Request Validation
To specify the validity of the request and indicate follow-up action authorized
- 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).
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
Code assigned by issuer to identify reason for rejection
- 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
Code identifying follow-up actions allowed
- 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".
Provider Information
To specify the identifying characteristics of a provider
- 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.
Code identifying the type of provider
- AD
- Admitting
- AT
- Attending
- BI
- Billing
- CO
- Consulting
- CV
- Covering
- H
- Hospital
- HH
- Home Health Care
- LA
- Laboratory
- OT
- Other Physician
- P1
- Pharmacist
- P2
- Pharmacy
- PC
- Primary Care Physician
- PE
- Performing
- R
- Rural Health Clinic
- RF
- Referring
- SK
- Skilled Nursing Facility
- SU
- Supervising
Code qualifying the Reference Identification
- If this segment is used to identify a type of specialty associated with the services identified in loop 2110D, use code PXC.
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this number for the reference number as qualified by the preceding data element (PRV02).
Dependent Demographic Information
To supply demographic information
- 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.
Code indicating the date format, time format, or date and time format
- Use this code to indicate the format of the date of birth that follows in DMG02.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
- Use this date for the date of birth of the dependent.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Dependent Relationship
To provide benefit information on insured entities
- 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.
Code indicating a Yes or No condition or response
- INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
- N
- No
Code indicating the relationship between two individuals or entities
- 01
- Spouse
- 19
- Child
- 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
Code identifying the specific type of item maintenance
- 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
Code identifying the reason for the maintenance change
- 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.
A generic number
- INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
- Use to indicate the birth order in the event of multiple births in association with the birth date supplied in DMG02.
Dependent Health Care Diagnosis Code
To supply information related to the delivery of health care
- 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.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
- BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data element has been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Dependent Date
To specify any or all of a date, a time, or a time period
- 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.
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
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- Use this code to specify the format of the date(s)/time(s) that follow in the next data element.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- Use this date for the date(s) as qualified by the preceding data elements.
Dependent Military Personnel Information
To report military service data
- 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.
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
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
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
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.
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
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
Expression of a date, a time, or range of dates, times or dates and times
- MPI07 indicates the date span of military service.
Dependent Eligibility or Benefit Information
To supply eligibility or benefit information
- 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.
Code identifying eligibility or benefit information
- EB01 qualifies EB06 through EB10.
- 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.
Code indicating the level of coverage being provided for this insured
- 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
Code identifying the classification of service
- Position of data in the repeating data element conveys no significance.
- 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
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
A description or number that identifies the plan or coverage
- 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.
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
Monetary amount
- 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.
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)
- 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.
Code specifying the type of quantity
- 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
Numeric value of quantity
- Use this number for the quantity value as qualified by the preceding data element (EB09).
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.
- 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
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.
- 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
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.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- Use this code to 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)
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- Use this ID number for the product/service code as qualified by the preceding data element.
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.
- Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
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.
- Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
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.
- Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
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.
- Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
- 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.
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.
A pointer to the diagnosis code in the order of importance to this service
- C004-01 identifies the primary diagnosis code for this service line.
- This first pointer designates the primary diagnosis for this 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.
A pointer to the diagnosis code in the order of importance to this service
- C004-02 identifies the second diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.
A pointer to the diagnosis code in the order of importance to this service
- C004-03 identifies the third diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.
A pointer to the diagnosis code in the order of importance to this service
- C004-04 identifies the fourth diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.
Health Care Services Delivery
To specify the delivery pattern of health care services
- 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.
Code specifying the type of quantity
- Required if HSD02 is used.
- DY
- Days
- FL
- Units
- HS
- Hours
- MN
- Month
- VS
- Visits
Numeric value of quantity
- Required if HSD01 is used.
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
To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes
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
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)
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)
Dependent Additional Identification
To specify identifying information
- 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.
Code qualifying the Reference Identification
- 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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this information for the reference number as qualified by the preceding data element (REF01).;
A free-form description to clarify the related data elements and their content
Dependent Eligibility/Benefit Date
To specify any or all of a date, a time, or a time period
- 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.
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