EB Eligibility or Benefit Information

To supply eligibility or benefit information

Position
Element
Name
Type
Requirement
Min
Max
Repeat
EB-01
Eligibility or Benefit Information Code
Identifier (ID)
Mandatory
1
2
1
Code identifying eligibility or benefit information
EB01 qualifies EB06 through EB10.
EB-02
Coverage Level Code
Identifier (ID)
Optional
3
3
1
Code indicating the level of coverage being provided for this insured
EB-03
Service Type Code
Identifier (ID)
Optional
1
2
99
Code identifying the classification of service
Position of data in the repeating data element conveys no significance.
EB-04
Insurance Type Code
Identifier (ID)
Optional
1
3
1
Code identifying the type of insurance policy within a specific insurance program
EB-05
Plan Coverage Description
String (AN)
Optional
1
50
1
A description or number that identifies the plan or coverage
EB-06
Time Period Qualifier
Identifier (ID)
Optional
1
2
1
Code defining periods
EB-07
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
EB-08
Percentage as Decimal
Decimal number (R)
Optional
1
10
1
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)
EB-09
Quantity Qualifier
Identifier (ID)
Conditional
2
2
1
Code specifying the type of quantity
P0910: If either EB-09 or EB-10 is present, then the other is required
EB-10
Quantity
Decimal number (R)
Conditional
1
15
1
Numeric value of quantity
EB-11
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
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.
EB-12
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
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.
EB-13
Composite Medical Procedure Identifier
Composite (composite)
Optional
1
01
Product/Service ID Qualifier
Identifier (ID)
Mandatory
2
2
-
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
C003-01 qualifies C003-02 and C003-08.
02
Product/Service ID
String (AN)
Mandatory
1
48
-
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.
03
Procedure Modifier
String (AN)
Optional
2
2
-
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.
04
Procedure Modifier
String (AN)
Optional
2
2
-
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.
05
Procedure Modifier
String (AN)
Optional
2
2
-
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.
06
Procedure Modifier
String (AN)
Optional
2
2
-
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.
07
Description
String (AN)
Optional
1
80
-
A free-form description to clarify the related data elements and their content
C003-07 is the description of the procedure identified in C003-02.
08
Product/Service ID
String (AN)
Optional
1
48
-
Identifying number for a product or service
C003-08 represents the ending value in the range in which the code occurs.
EB-14
Composite Diagnosis Code Pointer
Composite (composite)
Optional
1
01
Diagnosis Code Pointer
Numeric (N0)
Mandatory
1
2
-
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.
02
Diagnosis Code Pointer
Numeric (N0)
Optional
1
2
-
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.
03
Diagnosis Code Pointer
Numeric (N0)
Optional
1
2
-
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.
04
Diagnosis Code Pointer
Numeric (N0)
Optional
1
2
-
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.

Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference is provided for marketing purposes and is free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.