EDI 271 Health Care Eligibility/Benefit Information

Functional Group HB

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Eligibility/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 from health care information sources (i.e. - insurers, sponsors, payors) to health care information receivers (i.e. - physicians, hospitals, medical facilities) information about or changes to health care eligibility or benefits. This information includes but is not limited to: benefit status, explanation of benefit status, dependent coverage level, dates of coverage, covered days and/or non-covered days, amounts for co-insurance, co-pays, deductibles, exclusions and limitations.

Heading

Position
Segment
Name
Max use
  1. To indicate the start of a transaction set and to assign a control number

  2. To indicate the beginning of a transaction set.

Detail

Position
Segment
Name
Max use
  1. HL Loop Mandatory
    Repeat >1
    1. To identify dependencies among and the content of hierarchically related groups of data segments.

      Valid codes for HL03 to define levels are 20, 21, 22, and 23.
      The HL segment is the only mandatory segment within the HL loop, and by itself, the HL segment has no meaning.
    2. To uniquely identify a transaction to an application.

      If the Health Care Eligibility/Benefit Inquiry Transaction Set (270) includes a TRN segment, then the Health Care Eligibility/Benefit Information Transaction Set (271) must return the trace number identified in the TRN segment.
    3. To specify the validity of the request and to indicate follow-up action authorized.

    4. NM1 Loop Optional
      Repeat >1
      1. To supply the full name of an individual or organizational entity

      2. To specify identifying numbers.

      3. To specify additional names or those longer than 35 characters in length

      4. To specify the location of the named party

      5. To specify the geographic place of the named party

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

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

      8. To specify the identifying characteristics of a provider

        The PRV segment may only appear at the Eligibility or Benefit Information Receiver level (HL03 = 21).
      9. To supply demographic information

        The DMG segment may only appear at the Subscriber (HL03 = 22) and Dependent (HL03 = 23) levels.
      10. To provide benefit information on insured entities

        The INS segment may only appear at the Subscriber (HL03 = 22) and Dependent (HL03 = 23) levels.
      11. To specify any or all of a date, a time, or a time period

      12. EB Loop Optional
        Repeat >1
        1. To supply eligibility or benefit information

          The EB loop may only appear at the Subscriber (HL03 = 22) and Dependent (HL03 = 23) levels.
        2. To specify identifying numbers.

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

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

        5. To provide a free form format that would allow the transmission of text information.

        6. To indicate that the next segment begins a loop

        7. NM1 Loop Optional
          Repeat 1
          1. To supply the full name of an individual or organizational entity

          2. To specify additional names or those longer than 35 characters in length

          3. To specify the location of the named party

          4. To specify the geographic place of the named party

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

        8. To indicate that the loop immediately preceding this segment is complete

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

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