EDI
API DocsTerminal

EB Eligibility or Benefit Information

To supply eligibility or benefit information

Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
1390
Eligibility or Benefit Information Code
Identifier (ID)
Mandatory
1
2
25
Code identifying eligibility or benefit information
All EB01 values qualify EB06 through EB10. Position of data in the repeating data element conveys no significance.
Codes (53)
02
Coverage Level Code
Identifier (ID)
Optional
3
3
1
Code indicating the level of coverage being provided for this insured
Codes (25)
03
Service Type
Composite (composite)
Optional
99
01
Industry Code
String (AN)
Mandatory
1
30
-
Code indicating a code from a specific industry code list
C064-01 is the Service Type (Code Source 958).
02
Industry Code
String (AN)
Optional
1
30
-
Code indicating a code from a specific industry code list
C064-02 is the Service Type Descriptor (Code Source 981).
04
Insurance Product Code
Identifier (ID)
Optional
1
3
1
Code identifying the type of insurance policy within a specific insurance program for eligibility purposes.
05
Plan Coverage Description
String (AN)
Optional
1
50
1
A description or number that identifies the plan or coverage
06
Time Period Qualifier
Identifier (ID)
Optional
1
2
1
Code specifying periods
Codes (45)
07
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
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%)
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
Codes (1158)
10
Quantity
Decimal number (R)
Conditional
1
15
1
Numeric value of quantity
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.
Codes (9)
12
Network Indicator Code
Identifier (ID)
Optional
1
2
1
Code identifying a health plan network status.
Codes (4)
13
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.
Codes (544)
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.
14
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.
15
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
A "Y" indicates benefits are shared across Service Type Codes and Procedure Codes; an "N" indicates benefits are not shared.
Codes (9)
16
Health Care Services Review Requirement Code
Identifier (ID)
Optional
1
2
10
Code indicating the type of heath care service review required for the service.
Codes (9)
17
Health Care Code Information
Composite (composite)
Optional
99
01
Code List Qualifier Code
Identifier (ID)
Mandatory
1
3
-
Code identifying a specific industry code list
C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
Codes (1056)
02
Industry Code
String (AN)
Mandatory
1
30
-
Code indicating a code from a specific industry code list
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
03
Date Time Period Format Qualifier
Identifier (ID)
Conditional
2
3
-
Code indicating the date format, time format, or date and time format
P0304: If either C022-03 or C022-04 is present, then the other is required
C022-03 is the date format that will appear in C022-04.
Codes (42)
04
Date Time Period
String (AN)
Conditional
1
35
-
Expression of a date, a time, or range of dates, times or dates and times
05
Monetary Amount
Decimal number (R)
Optional
1
18
-
Monetary amount
06
Quantity
Decimal number (R)
Optional
1
15
-
Numeric value of quantity
07
Version Identifier
String (AN)
Optional
1
30
-
Revision level of a particular format, program, technique or algorithm
C022-07 qualifies C022-01.
08
Industry Code
String (AN)
Conditional
1
30
-
Code indicating a code from a specific industry code list
E0809: Only one of C022-08 or C022-09 may be present
C022-08 represents the ending value in a range of codes.
09
Industry Code
String (AN)
Conditional
1
30
-
Code indicating a code from a specific industry code list
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.
10
Industry Code
String (AN)
Optional
1
30
-
Code indicating a code from a specific industry code list
C022-10 is the attribute of the code in C022-02 from the same code list.

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Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are 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.