271 Eligibility, Coverage or Benefit Information

Functional Group HB

X12N Insurance Subcommittee

This Draft Standard for Trial Use 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.

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

    4. 2100 Loop Optional
      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 validity of the request and indicate follow-up action authorized

      8. To specify the identifying characteristics of a provider

      9. To supply demographic information

      10. To provide benefit information on insured entities

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

      12. To specify language, type of usage, and proficiency or fluency

      13. 2110 Loop Optional
        Repeat >1
        1. To supply eligibility or benefit information

        2. To specify the delivery pattern of health care services

        3. To specify identifying information

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

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

        6. To provide descriptions that identify a specific vehicle

        7. To describe a product or process in coded or free-form format

        8. To provide a description of real property

        9. To provide a description of personal property

        10. To specify basic item identification data

        11. To send additional information regarding a specific piece of equipment

        12. To provide safety data information to recipients of the transaction, including identification of the hazard that the material being described represents, and the organization or party which declared this material to be a hazard or established exposure limits or other guidelines for that material

        13. To specify a package description and other information

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

        15. 2115 Loop Optional
          Repeat >1
          1. To report information

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

          3. To indicate the total monetary amount

          4. To qualify percent amounts and supply percent amounts

          5. 2117 Loop Optional
            Repeat >1
            1. Code to transmit standard industry codes

            2. To indicate the total monetary amount

            3. To qualify percent amounts and supply percent amounts

        16. To indicate that the next segment begins a loop

        17. 2120 Loop Optional
          Repeat 1
          1. To supply the full name of an individual or organizational entity

          2. To specify additional names

          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

          6. To specify the identifying characteristics of a provider

        18. 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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