EDI 270 Health Care Eligibility/Benefit Inquiry

Functional Group HS

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Eligibility/Benefit Inquiry Transaction Set (270) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to inquire about the health care eligibility and benefits associated with a subscriber or a dependent under the subscriber's policy. A subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A dependent is a person who is affiliated with the subscriber such as spouse, child, etc., and therefore may be entitled to benefits.


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

  2. 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


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

    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. NM1 Loop Mandatory
      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 identifying characteristics of a provider

      8. To supply demographic information

      9. To provide benefit information on insured entities

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

      11. EQ Loop Optional
        Repeat 99
        1. To specify inquired eligibility or benefit information

        2. To indicate the total monetary amount.

        3. To specify identifying numbers.

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

  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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