EB Eligibility or Benefit Information

To supply eligibility or benefit information

Position
Element
Name
Type
Requirement
Min
Max
Repeat
EB01
Eligibility or Benefit Information Code
Identifier (ID)
Mandatory
1
2
1
Code identifying eligibility or benefit information
EB01 qualifies EB06 through EB10.
EB02
Coverage Level Code
Identifier (ID)
Optional
3
3
1
Code indicating the level of coverage being provided for this insured
EB03
Industry Code
String (AN)
Optional
1
30
99
Code indicating a code from a specific industry code list
Position of data in the repeating data element conveys no significance.
EB03 is the Service Type (Code Source 958).
EB04
Insurance Type Code
Identifier (ID)
Optional
1
3
1
Code identifying the type of insurance policy within a specific insurance program
EB05
Plan Coverage Description
String (AN)
Optional
1
50
1
A description or number that identifies the plan or coverage
EB06
Time Period Qualifier
Identifier (ID)
Optional
1
2
1
Code defining periods
EB07
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
EB08
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%)
EB09
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
EB10
Quantity
Decimal number (R)
Conditional
1
15
1
Numeric value of quantity
EB11
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.
EB12
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.
EB13
Composite Medical Procedure Identifier
Composite (composite)
Optional
99
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
80
-
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
80
-
Identifying number for a product or service
C003-08 represents the ending value in the range in which the code occurs.
09
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-09 modifies the value in C003-02 and C003-08.
10
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-10 modifies the value in C003-02 and C003-08.
11
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-11 modifies the value in C003-02 and C003-08.
12
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-12 modifies the value in C003-02 and C003-08.
EB14
Diagnosis Code Pointer
Numeric (N0)
Optional
1
2
12
A pointer to the diagnosis code in the order of importance to this service
The first pointer designates the primary diagnosis and remaining diagnosis pointers indicate declining level of importance.

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