270 Eligibility, Coverage or Benefit Inquiry

Functional Group HS

X12N Insurance Subcommittee

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

Heading

Position
Segment
Name
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

Detail

Position
Segment
Name
Max use
  1. 2000 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 Eligibility, Coverage or Benefit Inquiry Transaction Set (270) includes a TRN segment, then the Eligibility, Coverage or Benefit Information Transaction Set (271) must return the trace number identified in the TRN segment.
    3. 2100 Loop Mandatory
      Repeat >1
      1. To supply the full name of an individual or organizational entity

      2. To specify identifying information

      3. To specify additional names

      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. 2110 Loop Optional
        Repeat 99
        1. To specify inquired eligibility or benefit information

        2. To indicate the total monetary amount

        3. To provide descriptions that identify a specific vehicle

        4. To provide a description of real property

        5. To provide a description of personal property

        6. To report information

        7. To specify identifying information

        8. 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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