270/271 Health Care Eligibility Benefit Inquiry and Response (005010X279)

Required

I01

Authorization Information Qualifier

M 1

Code identifying the type of information in the Authorization Information

CODE

DEFINITION

No Authorization Information Present (No Meaningful Information in I02)

Additional Data Identification

Required

I02

Authorization Information

M 1

Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)

Required

I03

Security Information Qualifier

M 1

Code identifying the type of information in the Security Information

CODE

DEFINITION

No Security Information Present (No Meaningful Information in I04)

Password

Required

I04

Security Information

M 1

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

Required

I05

Interchange ID Qualifier

M 1

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

This ID qualifies the Sender in ISA06.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I06

Interchange Sender ID

M 1

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

Required

I05

Interchange ID Qualifier

M 1

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

This ID qualifies the Receiver in ISA08.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I07

Interchange Receiver ID

M 1

Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

Required

I08

Interchange Date

M 1

Date of the interchange

The date format is YYMMDD.

Required

I09

Interchange Time

M 1

Time of the interchange

The time format is HHMM.

Required

I65

Repetition Separator

M 1

Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator

Required

I11

Interchange Control Version Number

M 1

Code specifying the version number of the interchange control segments

CODE

DEFINITION

00501

Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02.
Must be a positive unsigned number and must be identical to the value in IEA02.

Required

I13

Acknowledgment Requested

M 1

Code indicating sender's request for an interchange acknowledgment

See Section B.1.1.5.1 for interchange acknowledgment information.

CODE

DEFINITION

No Interchange Acknowledgment Requested

Interchange Acknowledgment Requested (TA1)

Required

I14

Interchange Usage Indicator

M 1

Code indicating whether data enclosed by this interchange envelope is test, production or information

CODE

DEFINITION

Production Data

Test Data

Required

I15

Component Element Separator

M 1

Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

GS*HB - FUNCTIONAL GROUP HEADER

X12 Name:

Functional Group Header

X12 Purpose:

To indicate the beginning of a functional group and to provide control information

X12 Comments:

A functional group of related transaction sets, within the scope of X12 standards, consists of a collection of similar transaction sets enclosed by a functional group header and a functional group trailer.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GS✱XX✱SENDER CODE✱RECEIVER CODE✱20071231✱0802✱1✱X✱005010X000~

✱

✱

Application
Send's Code

2/15

✱

124

Application
Rec's Code

✱

✱

✱

✱

Responsible
Agency Code

✱

Required

479

Functional Identifier Code

M 1

Code identifying a group of application related transaction sets

This is the 2-character Functional Identifier Code assigned to each transaction set by X12. The specific code for a transaction set defined by this implementation guide is presented in section 1.2, Version Information.

CODE

DEFINITION

Eligibility, Coverage or Benefit Information (271)HS Eligibility, Coverage or Benefit Inquiry (270)

Required

142

Application Sender's Code

M 1

2/15

Code identifying party sending transmission; codes agreed to by trading partners

Use this code to identify the unit sending the information.

Required

124

Application Receiver's Code

M 1

2/15

Code identifying party receiving transmission; codes agreed to by trading partners

Use this code to identify the unit receiving the information.

Required

373

Date

M 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEMANTIC: GS04 is the group date.

Use this date for the functional group creation date.

Required

337

Time

M 1

4/8

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

SEMANTIC: GS05 is the group time.

Use this time for the creation time. The recommended format is HHMM.

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

SEMANTIC: The data interchange control number GS06 in this header must be identical to the same data element in the associated functional group trailer, GE02.

For implementations compliant with this guide, GS06 must be unique within a single transmission (that is, within a single ISA to IEA enveloping structure). The authors recommend that GS06 be unique within all transmissions over a period of time to be determined by the sender.

Required

455

Responsible Agency Code

M 1

1/2

Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

CODE

DEFINITION

Accredited Standards Committee X12

Required

480

Version / Release / Industry Identifier Code

M 1

1/12

Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed

INDUSTRY NAME: Version, Release, or Industry Identifier Code

This is the unique Version/Release/Industry Identifier Code assigned to an implementation by X12N. The specific code for a transaction set defined by this implementation guide is presented in section 1.2, Version Information.

CODE SOURCE 881:Version / Release / Industry Identifier Code

CODE

DEFINITION

005010X279A1

Health Care Eligibility Benefit Inquiry and Response

ST*270 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

To indicate the start of a transaction set and to assign a control number

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this control segment to mark the start of a transaction set. One ST segment exists for every transaction set that occurs within a functional group.

TR3 Example:

ST✱270✱0001✱005010X279A1~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

Code uniquely identifying a Transaction Set

SEMANTIC: The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).

Use this code to identify the transaction set ID for the transaction set that will follow the ST segment. Each X12 standard has a transaction set identifier code that is unique to that transaction set.

CODE

DEFINITION

270

Eligibility, Coverage or Benefit Inquiry

Required

329

Transaction Set Control Number

M 1

4/9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with the number, for example "0001", and increment from there. This number must be unique within a specific group and interchange, but can repeat in other groups and interchanges.
Use the corresponding value in SE02 for this transaction set.

Required

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

SEMANTIC: The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.

This element must be populated with 005010X279A1.
This element contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST/SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.

CODE

DEFINITION

005010X279A1

Health Care Eligibility Benefit Inquiry and Response

BHT*0022 - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to start the transaction set and indicate the sequence of the hierarchical levels of information that will follow in Table 2.

TR3 Example:

BHT✱0022✱13✱199800114000001✱19980101✱1400~
BHT✱0022✱01✱✱19980101✱1400✱RT~

BHT

✱

✱

✱

✱

✱

✱

Transaction
Type Code

Loop 2000A - INFORMATION SOURCE LEVEL

Required

1005

Hierarchical Structure Code

M 1

Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set

Use this code to specify the sequence of hierarchical levels that may appear in the transaction set. This code only indicates the sequence of the levels, not the requirement that all levels be present. For example, if code "0022" is used, the dependent level may or may not be present for each subscriber.

CODE

DEFINITION

0022

Information Source, Information Receiver, Subscriber, Dependent

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Cancellation

Use this code to cancel a previously submitted 270 transaction that used a BHT06 code of "RT". Only 270 transactions that used a BHT06 code of "RT" can be canceled. The cancellation 270 transaction must also contain a BHT06 of "RT".

Request

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.

SITUATIONAL RULE: Required when the transaction is processed in Real Time. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Submitter Transaction Identifier

Due to the nature of batch transaction processing, the receiver of the 270 transaction (whether it is a clearinghouse or information source) may or may not be able to return the 270 BHT03 value in the 271 BHT03. See Section 1.4.6 Information Linkage for additional information and requirements.
This element is to be used to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. This identifier is to be returned in the corresponding 271 transaction's BHT03. This identifier will only be returned by the last entity to handle the 270. This identifier will not be passed through the complete life of the transaction.

Required

373

Date

O 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEMANTIC: BHT04 is the date the transaction was created within the business application system.

INDUSTRY NAME: Transaction Set Creation Date

Use this date for the date the transaction set was generated.

Required

337

Time

O 1

4/8

SEMANTIC: BHT05 is the time the transaction was created within the business application system.

INDUSTRY NAME: Transaction Set Creation Time

Use this time for the time the transaction set was generated.

Situational

640

Transaction Type Code

O 1

Code specifying the type of transaction

SITUATIONAL RULE: Required when the Information Source supports Spend Down transactions and the Information Receiver is using this transaction for Spend Down purposes. If not required by this implementation guide, do not send.

Certain Medicaid programs support additional functionality for Spend Down. Use this code when necessary to further specify the type of transaction to a Medicaid program that supports this functionality.

CODE

DEFINITION

Spend Down

"Spend Down" is a term used by certain Medicaid programs when a recipient must pay a predetermined amount out of his or her own pocket before full coverage benefits are applied. In order to decrement the amount the recipient must pay out of pocket, a 270 transaction must be sent in with this code.

In the event that the service is not rendered and the Spend Down amount is returned to the recipient, an additional 270 must be sent in with a BHT02 with a code "01" to cancel the Spend Down.

HL - INFORMATION SOURCE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to identify the hierarchical or entity level of information being conveyed. The HL structure allows for the efficient nesting of related occurrences of information. The developers' intent is to clearly identify the relationship of the patient to the subscriber and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient) can be grouped together under the same provider or the information for multiple providers or information receivers can be grouped together for the same payer or information source. See Section 1.3.2 for limitations on the number of occurrences of patients.
In a batch environment, only one Loop 2000A (Information Source) loop is to be created for each unique information source in a transaction. Each Loop 2000B (Information Receiver) loop that is subordinate to an information source is to be contained within only one Loop 2000A loop. There has been a misuse of the HL structure creating multiple Loops 2000As for the same information source. This is not the developer's intended use of the HL structure, and defeats the efficiencies that are designed into the HL structure.
An example of the overall structure of the transaction set when used in batch mode is:

Information Source (Loop 2000A)
Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.

Use this sequentially assigned positive number to identify each specific occurrence of an HL segment within a transaction set. The first HL segment in the transaction must begin with the number 1 and be incremented by 1 for each successive occurrence of the HL segment within that specific transaction set (ST through SE).
An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~

Not Used

734

Hierarchical Parent ID Number

O 1

1/12

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

COMMENT: HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.

All data that follows this HL segment is associated with the Information Source identified by the level code. This association continues until the next occurrence of an HL segment.

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

Because of the hierarchical structure, and there will always be an Information Receiver HL subordinate to this Information Source HL the code value in the HL04 at the Loop 2000A level must always be "1".

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 - INFORMATION SOURCE NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this NM1 loop to identify an entity by name and/or identification number. This NM1 loop is used to identify the eligibility or benefit information source, (e.g., insurance company, HMO, IPA, employer).

TR3 Example:

NM1✱PR✱2✱ACE INSURANCE COMPANY✱✱✱✱✱PI✱87728~

NM1

✱

✱

Loop 2000B - INFORMATION RECEIVER LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Third-Party Administrator

Employer

Gateway Provider

Plan Sponsor

Payer

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

Use this code to indicate whether the entity is an individual person or an organization.

CODE

DEFINITION

Person

Use this code only if the information source is a Gateway Provider and an individual.

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Information Source Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 is "1" and the identifier in 2100A NM109 and Last Name in 2100A NM103 and First Name in 2100A NM104 and Name Suffix in 2100A NM107 if sent, are not sufficient to identify the source of eligibility or benefit information. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Information Source Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 is "1" and the identifier in 2100A NM109 and Last Name in 2100A NM103 and First Name in 2100A NM104 and Middle Name in 2100A NM105 if sent, are not sufficient to identify the source of eligibility or benefit information. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Information Source Name Suffix

Required

Identification Code Qualifier

O 1

1/2

Code designating the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

Use code value "XX" if the information source is a provider and the CMS National Provider Identifier is mandated for use.

Use "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE

DEFINITION

Employer's Identification Number

Electronic Transmitter Identification Number (ETIN)

Federal Taxpayer's Identification Number

National Association of Insurance Commissioners (NAIC) Identification

Payor Identification

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Use this reference number as qualified by the preceding data element (NM108).

INDUSTRY NAME: Information Source Primary Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

HL - INFORMATION RECEIVER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to identify the hierarchical or entity level of information being conveyed. The HL structure allows for the efficient nesting of related occurrences of information. The developers' intent is to clearly identify the relationship of the patient to the subscriber and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient) can be grouped together under the same provider or the information for multiple providers or information receivers can be grouped together for the same payer or information source. See Section 1.3.2 for limitations on the number of occurrences of patients.
In a batch environment, only one Loop 2000B (Information Receiver) loop is to be created for each unique information receiver within an Loop 2000A (Information Source) loop. Each Loop 2000C (Subscriber) loop that is subordinate to an information receiver is to be contained within only one Loop 2000B loop. There has been a misuse of the HL structure creating multiple Loop 2000Bs for the same information receiver within an information source loop. This is not the developer's intended use of the HL structure, and defeats the efficiencies that are designed into the HL structure.
An example of the overall structure of the transaction set when used in batch mode is:

Information Source (Loop 2000A)
Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry

TR3 Example:

HL✱2✱1✱21✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

Use this sequentially assigned positive number to identify each specific occurrence of an HL segment within a transaction set. The first HL segment in the transaction must begin with the number 1 and be incremented by 1 for each successive occurrence of the HL segment within that specific transaction set (ST through SE).
An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Use this code to identify the specific Information Source to which this Information Receiver is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

All data that follows this HL segment is associated with the Information Receiver identified by the level code. This association continues until the next occurrence of an HL segment.

CODE

DEFINITION

Information Receiver

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

Because of the hierarchical structure, and there will always be a Subscriber HL subordinate to this Information Receiver HL, the code value in the HL04 at the Loop 2000B level must always be "1".

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 - INFORMATION RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to identify an entity by name and/or identification number. This NM1 loop is used to identify the eligibility/benefit information receiver (e.g., provider, medical group, employer, IPA, or hospital).

TR3 Example:

NM1✱1P✱1✱JONES✱MARCUS✱✱✱MD✱34✱111223333~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Provider

Third-Party Administrator

Employer

Hospital

Facility

Gateway Provider

Plan Sponsor

Payer

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

Use this code to indicate whether the entity is an individual person or an organization.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Information Receiver Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when 2100B NM102 is "1". If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when 2100B NM104 is present and Name Suffix in 2100B NM107 if sent, are not sufficient to identify the information receiver. If not required by this implementation guide and NM104 is present, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Information Receiver Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when 2100B NM104 is present and Middle Name in 2100B NM105 if sent, are not sufficient to identify the information receiver. If not required by this implementation guide and NM104 is present, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Information Receiver Name Suffix

Use this only if NM102 is "1".

Required

Identification Code Qualifier

O 1

1/2

Code designating the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

Use this element to qualify the identification number submitted in NM109. This is the number that the information source associates with the information receiver. Because only one number can be submitted in NM109, the following hierarchy must be used. Additional identifiers are to be placed in the REF segment. If the information receiver is a provider and the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate, code value "XX" must be used. Otherwise, one of the following codes may be used with the following hierarchy applied: Use the first code that applies: "SV", "PP", "FI", "34". The code "SV" is recommended to be used prior to the mandated use of the National Provider ID.

Use "PI" when Information Receiver is a payer and "XV" is not used.

Use "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

If the information receiver is an employer, use code value "24".

CODE

DEFINITION

Employer's Identification Number

Use this code only when the 270/271 transaction sets are used by an employer inquiring about eligibility and benefits of their employees.

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Federal Taxpayer's Identification Number

Payor Identification

Use this code only when the 270/271 transaction sets are used between two payers.

Pharmacy Processor Number

Service Provider Number

Use this code for the identification number assigned by the information source to be used by the information receiver in health care transactions.

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Use this reference number as qualified by the preceding data element (NM108).

INDUSTRY NAME: Information Receiver Identification Number

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - INFORMATION RECEIVER ADDITIONAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information in 2100B NM1 is not sufficient to identify the information receiver. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

TR3 Notes:

Use this segment when needed to convey other or additional identification numbers for the information receiver. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100B loop.

TR3 Example:

REF✱EO✱477563928~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number that is following in REF02.
Only one occurrence of each REF01 code value may be used in the 2100B loop.

CODE

DEFINITION

State License Number

The state assigning the license number must be identified in REF03.

Medicare Provider Number

Medicaid Provider Number

Facility ID Number

Personal Identification Number (PIN)

Contract Number

Electronic device pin number

Submitter Identification Number

HPI

Centers for Medicare and Medicaid Services National Provider Identifier

The Centers for Medicare and Medicaid Services National Provider Identifier may be used in this segment prior to being mandated for use.

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

User Identification

Provider Plan Network Identification Number

Facility Network Identification Number

Prior Identifier Number

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Federal Taxpayer's Identification Number

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Information Receiver Additional Identifier

Use this reference number as qualified by the preceding data element (REF01).

Situational

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when the identifier supplied in REF02 is the State License Number. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver Additional Identifier State

Use this element for the two character state ID of the state assigning the identifier supplied in REF02. See Code source 22: States and Outlying Areas of the U.S.

Not Used

C040

Reference Identifier

O 1

N3 - INFORMATION RECEIVER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver is a provider who has multiple locations and it is needed to identify the location relative to the request. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

TR3 Example:

N3✱201 PARK AVENUE✱SUITE 300~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Information Receiver Address Line

Use this information for the first line of the address information.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line exists. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver Additional Address Line

N4 - INFORMATION RECEIVER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Information Receiver City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

SITUATIONAL RULE: Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send.

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

PRV - INFORMATION RECEIVER PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Receiver believes Provider Information is relevant to the request and is necessary to convey the provider's role in or taxonomy code related to the eligibility/benefit being inquired about and the provider is also the Information Receiver. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

TR3 Notes:

For example, if the Information Receiver is also the Referring Provider, this PRV segment would be used to identify the provider's role.
PRV02 qualifies PRV03.

TR3 Example:

PRV✱RF✱PXC✱207Q00000X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Attending

Billing

Consulting

Covering

Hospital

Home Health Care

Laboratory

Other Physician

Pharmacist

Pharmacy

Primary Care Physician

Performing

Rural Health Clinic

Referring

Submitting

Skilled Nursing Facility

Supervising

Situational

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when the Information Receiver believes Provider Information is relevant to the request and is necessary to convey the provider's taxonomy code in relation to the eligibility/benefit being inquired about and the provider is also the Information Receiver. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Information Receiver Provider Taxonomy Code

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

HL - SUBSCRIBER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

If the transaction set is to be used in a real time mode (see section 1.4.3 for additional detail), it is required that the 270 transaction contain only one patient request (except as allowed in Section 1.4.3 Exceeding the Number of Patient Requests). One patient request (See Section 1.4.2) is defined as the occurrence of one or more 2110 (EQ) loops for an individual. If the patient is the subscriber, the patient request is the existence of at least one 2110C loop. If the patient is the dependent, the patient request is the existence of at least one 2110D loop. In the event the patient has more than one occurrence of a 2110 (EQ) loop, that still constitutes one patient request.

If the transaction set is to be used in a batch mode (see section 1.4.3 for additional detail), it is required that the 270 transaction contain a maximum of ninety-nine patient requests (except as allowed in Section 1.4.3 Exceeding the Number of Patient Requests). One patient request (See Section 1.4.2) is defined as the occurrence of one or more 2110 (EQ) loops for an individual. If the patient is the subscriber, the patient request is the existence of at least one 2110C loop. If the patient is the dependent, the patient request is the existence of at least one 2110D loop. In the event the patient has more than one occurrence of a 2110 (EQ) loop, that still constitutes one patient request.

Although it is not recommended, if the number of patients is to be greater than one for real time mode or greater than ninety-nine for batch mode, the trading partners (the Information Source, the Information Receiver and the clearinghouse the transaction is routed through, if there is one involved) must all agree to exceed the number of patient requests and agree to a reasonable limit. See Section 1.4.3 Exceeding the Number of Patient Requests for additional information.
Use this segment to identify the hierarchical or entity level of information being conveyed. The HL structure allows for the efficient nesting of related occurrences of information. The developers' intent is to clearly identify the relationship of the patient to the subscriber and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient) can be grouped together under the same provider or the information for multiple providers or information receivers can be grouped together for the same payer or information source. See Section 1.3.2 for limitations on the number of occurrences of patients.
An example of the overall structure of the transaction set when used in batch mode is:

Information Source (Loop 2000A)
Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry

TR3 Example:

HL✱3✱2✱22✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

Use this sequentially assigned positive number to identify each specific occurrence of an HL segment within a transaction set. The first HL segment in the transaction must begin with the number 1 and be incremented by 1 for each successive occurrence of the HL segment within that specific transaction set (ST through SE).
An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~
HL*3*2*22*1~
NM1*IL*1*SMITH*ROBERT*B***MI*11122333301~
HL*4*3*23*0~
NM1*03*1*SMITH*MARY*LOU~
Eligibility/Benefit Data
HL*5*2*22*0~
NM1*IL*1*BROWN*JOHN*E***MI*22211333301~
Eligibility/Benefit Data

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Use this code to identify the specific Information Receiver to which this Subscriber is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

All data that follows this HL segment is associated with the Subscriber identified by the level code. This association continues until the next occurrence of an HL segment.

CODE

DEFINITION

Subscriber

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

If there is a Loop 2000D (Dependent) level subordinate to the current Loop 2000C, the value must be "1". If there is no Loop 2000D (Dependent) level subordinate to the current Loop 2000C, the value must be "0" (zero).

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

TRN*1 - SUBSCRIBER TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

X12 Set Notes:

NOTE: 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.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when information receiver or clearinghouse intends to use the TRN segment as a tracing mechanism for the eligibility transaction and the subscriber is the patient. If not required by this implementation guide, do not send.

TR3 Notes:

The information receiver may assign one TRN segment in this loop if the subscriber is the patient. A clearinghouse may assign one TRN segment in this loop if the subscriber is the patient. See Section 1.4.6 Information Linkage.
This segment must not be used if the subscriber is not the patient. See section 1.4.2. Basic Concepts.
Trace numbers assigned at the subscriber level are intended to allow tracing of an eligibility/benefit transaction when the subscriber is the patient.

TR3 Example:

TRN✱1✱98175-012547✱8877281234✱RADIOLOGY~TRN✱1✱109834652831✱WXYZCLEARH✱REALTIME~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Trace Number

Use this number for the trace or reference number assigned by the information receiver or clearinghouse.

Required

509

Originating Company Identifier

O 1

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this number for the identification number of the company that assigned the trace or reference number specified in the previous data element (TRN02).

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN04 identifies a further subdivision within the organization.

SITUATIONAL RULE: Required when it is necessary to further identify a specific component of the company identified in the previous data element (TRN03). If not required by this implementation guide, do not send.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

This information allows the originating company to further identify a specific division or group within that organization that was responsible for assigning the trace or reference number.

NM1*IL - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to identify an entity by name and/or identification number. Use this NM1 loop to identify the insured or subscriber.
Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
In worker's compensation or other property and casualty transactions, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.

TR3 Example:

NM1✱IL✱1✱SMITH✱JOHN✱L✱✱✱MI✱444115555~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

Use this code to indicate whether the entity is an individual person or an organization.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the subscriber is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).ORRequired when the subscriber is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Last Name (See Section 1.4.8).ORRequired when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).ORRequired when NM102 = 2 and needed for worker's compensation or other property and casualty inquiries.If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Last Name

Use this name for the subscriber's last name.
Information sources cannot require subscriber's name suffix be sent as a part of the subscriber's last name.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the subscriber is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).ORRequired when the subscriber is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's First Name (See Section 1.4.8).ORRequired when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

Use this name for the subscriber's first name.

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Middle Name or Initial

Use this name for the subscriber's middle name or initial.

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

INDUSTRY NAME: Subscriber Name Suffix

Use this for the suffix to an individual's name; e.g., Sr., Jr. or III.

Situational

Identification Code Qualifier

O 1

1/2

Code designating the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when either the subscriber or dependent is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).ORRequired when either the subscriber or dependent is the patient and the information receiver is utilizing one of the Required Alternate Search Options (See Section 1.4.8).ORRequired when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).If not required by this implementation guide, do not send.

Use this element to qualify the identification number submitted in NM109. This is the primary number that the information source associates with the subscriber.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of the Department of Health and Human Services may adopt a standard individual identifier for use in this transaction.

Member Identification Number

This code may only be used prior to the mandated use of code "II". This is the unique number the payer or information source uses to identify the insured (e.g., Health Insurance Claim Number, Medicaid Recipient ID Number, HMO Member ID, etc.).

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Primary Identifier

Use this reference number as qualified by the preceding data element (NM108).

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - SUBSCRIBER ADDITIONAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
OR
Required when this segment is used to transmit the Patient Account Number when REF01 = EJ (see Section 1.4.6).
OR
Required when this segment is used to transmit the Provider's Contract Number when REF01 = CT.
If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

TR3 Notes:

Use this segment when needed to convey identification numbers other than or in addition to the Member Identification Number. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100C loop.
Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Numbers are to be provided in the NM1 segment as a Member Identification Number when it is the primary number an information source knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.

TR3 Example:

REF✱1L✱660415~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number that is following in REF02.
Only one occurrence of each REF01 code value may be used in the 2100C loop.

CODE

DEFINITION

Plan Number

Group or Policy Number

Use this code only if it cannot be determined if the number is a Group Number or a Policy number. Use codes "IG" or "6P" when they can be determined.

Member Identification Number

Use only after the Unique Patient Identifier is available and has been provided in the NM109, but use of the UPI has not been mandated.

Case Number

Uses this code to identify the Case Number assigned to the subscriber by the information source.

Group Number

Contract Number

This code is to be used only to identify the provider's contract number of the provider identified in the PRV segment of Loop 2100C. This code is only to be used once the CMS National Provider Identifier has been mandated for use, and must be sent if required in the contract between the Information Receiver identified in Loop 2100B and the Information Source identified in Loop 2100A.

Medical Record Identification Number

Patient Account Number

Health Insurance Claim (HIC) Number

See segment note 2.

Identification Card Serial Number

Use this code when the Identification Card has a number in addition to the Member Identification Number or Identity Card Number. The Identification Card Serial Number uniquely identifies the card when multiple cards have been or will be issued to a member (e.g., on a monthly basis, replacement cards). This is particularly prevalent in the Medicaid environment.

Identity Card Number

Use this code when the Identity Card Number is different than the Member Identification Number. This is particularly prevalent in the Medicaid environment.

Insurance Policy Number

Plan Network Identification Number

Medicaid Recipient Identification Number

See segment note 2.

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Agency Claim Number

This code is only to be used when submitting an eligibility request to a Property and Casualty payer. Use this code to identify the Property and Casualty Claim Number associated with the subscriber. This code is not a HIPAA requirement as of this writing.

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Supplemental Identifier

Use this reference number as qualified by the preceding data element (REF01).

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

TR3 Example:

N3✱15197 BROADWAY AVENUE✱APT 215~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

Use this information for the first line of the address information.

Situational

166

Address Information

O 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

Use this information for the second line of the address information.

N4 - SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Subscriber City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

INDUSTRY NAME: Subscriber Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

PRV - PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information source is known to process this information in creating a 271 response and the information receiver feels it is necessary to identify a specific provider or to associate a specialty type related to the service identified in the 2110C loop. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

TR3 Notes:

This segment must not be used to identify the information receiver or the information receiver's specialty type, unless the information is different from that sent in the 2100B loop.
If identifying a specific provider, use this segment to convey specific information about a provider's role in the eligibility/benefit being inquired about when the provider is not the information receiver. For example, if the information receiver is a hospital and a referring provider must be identified, this is the segment where the referring provider would be identified.
If identifying a specific provider, this segment contains reference identification numbers, all of which may be used up until the time the National Provider Identifier (NPI) is mandated for use. After the NPI is mandated, only the code for National Provider Identifier may be used.
If identifying a type of specialty associated with the services identified in loop 2110C, use code PXC in PRV02 and the appropriate code in PRV03.
PRV02 qualifies PRV03.

TR3 Example:

PRV✱RF✱EI✱9991234567~PRV✱RF✱PXC✱207Q00000X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Attending

Billing

Consulting

Covering

Hospital

Home Health Care

Laboratory

Other Physician

Pharmacist

Pharmacy

Primary Care Physician

Performing

Rural Health Clinic

Referring

Skilled Nursing Facility

Supervising

Situational

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when the information source is known to process this information in creating a 271 response and the information receiver feels it is necessary to identify a specific provider or to associate a specialty type related to the service identified in the 2110C loop. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

If this segment is used to identify a specific provider and the National Provider ID is mandated for use, code value "HPI" must be used, otherwise one of the other code values may be used.
If this segment is used to identify a type of specialty associated with the services identified in loop 2110C, use code PXC.

CODE

DEFINITION

Servicer

Use this code for the identification number assigned by the information source to be used by the information receiver in health care transactions.

National Council for Prescription Drug Programs Pharmacy Number

CODE SOURCE: 307: National Council for Prescription Drug Programs Pharmacy Number

Employer's Identification Number

HPI

Centers for Medicare and Medicaid Services National Provider Identifier

Required value when identifying a specific provider when the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used.

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Federal Taxpayer's Identification Number

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when PRV02 is used. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Identifier

Use this reference number as qualified by the preceding data element (PRV02).

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

DMG*D8 - SUBSCRIBER DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

P0102
If either DMG01 or DMG02 is present, then the other is required.
P1011
If either DMG10 or DMG11 is present, then the other is required.
C1105
If DMG11 is present, then DMG05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the subscriber is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).
OR
Required when the subscriber is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Date of Birth (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment when needed to convey birth date or gender demographic information for the subscriber.
Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.

TR3 Example:

DMG✱D8✱19430917✱M~

DMG

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Situational

1250

Date Time Period Format Qualifier

O 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when the subscriber is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).ORRequired when the subscriber is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Date of Birth (See Section 1.4.8).ORRequired when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).If not required by this implementation guide, do not send.

Use this code to indicate the format of the date of birth that follows in DMG02.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

1251

Date Time Period

O 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when the subscriber is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).ORRequired when the subscriber is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Date of Birth (See Section 1.4.8).ORRequired when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Birth Date

Use this date for the date of birth of the subscriber.

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

INDUSTRY NAME: Subscriber Gender Code

Use this code to indicate the subscriber's gender.

CODE

DEFINITION

Female

Male

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

O 10

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

O 1

1/3

Not Used

1271

Industry Code

O 1

1/30

INS*Y - MULTIPLE BIRTH SEQUENCE NUMBER

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit information on insured entities

X12 Syntax:

P1112
If either INS11 or INS12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver believes it is necessary to identify the birth sequence of the subscriber in the case of multiple births with the same birth date for an Alternate Search Option supported by the Information Source (See Section 1.4.8). If not required by this implementation guide, do not send.

TR3 Notes:

This segment must not be used if the subscriber is not part of a multiple birth.

TR3 Example:

INS✱Y✱18✱✱✱✱✱✱✱✱✱✱✱✱✱✱✱3~

INS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Insured Indicator

The value Y is used to satisfy X12 syntax.

CODE

DEFINITION

Yes

The value Y is used to satisfy X12 syntax. This data has no business purpose and must not be used to indicate if the insured is a subscriber.

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

The value 18 is used only to satisfy X12 syntax.

CODE

DEFINITION

Self

The value 18 is used to satisfy X12 syntax. This data has no business purpose and must not be used to indicate the Individual's relationship to the insured.

Not Used

875

Maintenance Type Code

O 1

Not Used

1203

Maintenance Reason Code

O 1

2/3

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Required

1470

Number

O 1

1/9

A generic number

SEMANTIC: INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).

INDUSTRY NAME: Birth Sequence Number

Use to indicate the birth order in the event of multiple births in association with the birth date supplied in DMG02.

HI - SUBSCRIBER HEALTH CARE DIAGNOSIS CODE

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver believes the Diagnosis information is relevant to the inquiry, the information is available and if the information source supports or is believed to support this level of functionality. If not required by this implementation guide, do not send.

TR3 Notes:

Use the HI segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment. The information source must not use information in an HI segment of the 270 transaction in the determination of eligibility or benefits for the subscriber if that information cannot be returned in the 271 response.
Use this segment to identify Diagnosis codes as they relate to the information provided in the EQ segments.
Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.

TR3 Example:

HI✱BK:8901✱BF:87200✱BF:5559~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.

E codes are Not Used in HI01 except when defined by the claims processor. E codes may be put in any other HI element using BF as the qualifier.
The diagnosis listed in this element is assumed to be the principal diagnosis.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABK

International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

1-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1-4

1251

Date Time Period

O 1

1/35

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

O 1

1/30

Not Used

1-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when it is necessary to report an additional diagnosis and the preceding HI data element has been used to report other diagnoses. If not required by this implementation guide, do not send.

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

2-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

2-4

1251

Date Time Period

O 1

1/35

Not Used

2-5

782

Monetary Amount

O 1

1/18

Not Used

2-6

380

Quantity

O 1

1/15

Not Used

2-7

799

Version Identifier

O 1

1/30

Not Used

2-8

1271

Industry Code

O 1

1/30

Not Used

2-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

SITUATIONAL RULE: Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

3-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

3-4

1251

Date Time Period

O 1

1/35

Not Used

3-5

782

Monetary Amount

O 1

1/18

Not Used

3-6

380

Quantity

O 1

1/15

Not Used

3-7

799

Version Identifier

O 1

1/30

Not Used

3-8

1271

Industry Code

O 1

1/30

Not Used

3-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

4-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

4-4

1251

Date Time Period

O 1

1/35

Not Used

4-5

782

Monetary Amount

O 1

1/18

Not Used

4-6

380

Quantity

O 1

1/15

Not Used

4-7

799

Version Identifier

O 1

1/30

Not Used

4-8

1271

Industry Code

O 1

1/30

Not Used

4-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

5-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

5-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

5-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

5-4

1251

Date Time Period

O 1

1/35

Not Used

5-5

782

Monetary Amount

O 1

1/18

Not Used

5-6

380

Quantity

O 1

1/15

Not Used

5-7

799

Version Identifier

O 1

1/30

Not Used

5-8

1271

Industry Code

O 1

1/30

Not Used

5-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

6-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

6-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

6-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

6-4

1251

Date Time Period

O 1

1/35

Not Used

6-5

782

Monetary Amount

O 1

1/18

Not Used

6-6

380

Quantity

O 1

1/15

Not Used

6-7

799

Version Identifier

O 1

1/30

Not Used

6-8

1271

Industry Code

O 1

1/30

Not Used

6-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

7-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

7-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

7-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

7-4

1251

Date Time Period

O 1

1/35

Not Used

7-5

782

Monetary Amount

O 1

1/18

Not Used

7-6

380

Quantity

O 1

1/15

Not Used

7-7

799

Version Identifier

O 1

1/30

Not Used

7-8

1271

Industry Code

O 1

1/30

Not Used

7-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

8-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

8-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

8-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

8-4

1251

Date Time Period

O 1

1/35

Not Used

8-5

782

Monetary Amount

O 1

1/18

Not Used

8-6

380

Quantity

O 1

1/15

Not Used

8-7

799

Version Identifier

O 1

1/30

Not Used

8-8

1271

Industry Code

O 1

1/30

Not Used

8-9

1073

Yes/No Condition or Response Code

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

DTP - SUBSCRIBER DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver wishes to convey the plan date(s) for the subscriber in relation to the eligibility/benefit inquiry. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.
OR
Required when utilizing a search option other than either the Primary Search Option or a Required Alternate Search Option identified in section 1.4.8 which requires the ID Card Issue Date. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.

TR3 Notes:

Absence of a Plan date indicates the request is for the date the transaction is processed and the information source is to process the transaction in the same manner as if the processing date was sent.
Use this segment to convey the plan date(s) for the subscriber or for the issue date of the subscriber's identification card for the information source.
When using code "291" (Plan) at this level, it is implied that these dates apply to all of the Eligibility or Benefit Inquiry (EQ) loops that follow. If there is a need to supply a different Plan date for a specific EQ loop, it must be provided in the DTP segment within the EQ loop and it will only apply to that EQ loop.

TR3 Example:

DTP✱291✱D8✱20051015~

DTP

✱

✱

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

102

Issue

Used for the ID Card Issue Date if utilizing a search option other than the Primary or one of the Required Alternate Search Options identified in section 1.4.8 and the Card Issue Date is present on the identification card and is available.

291

Plan

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

Use this date for the date(s) as qualified by the preceding data elements.

EQ - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

X12 Name:

Eligibility or Benefit Inquiry

X12 Purpose:

To specify inquired eligibility or benefit information

X12 Syntax:

R0102
At least one of EQ01 or EQ02 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the subscriber is the patient whose eligibility or benefits are being verified. If not required by this implementation guide, do not send.

TR3 Notes:

When the subscriber is not the patient, the 2110C EQ segment must not be used. When the transaction is used in a batch environment, it is possible to have both 2110C and 2110D EQ segments when the subscriber and dependent(s) are patients whose eligibility or benefits are being verified. See Section 1.4.3 Batch and Real Time for additional information.
The 2110C EQ segment begins the 2110C loop.
If the EQ segment is used, either EQ01 - Service Type Code or EQ02 - Composite Medical Procedure Identifier must be used. Only EQ01 or EQ02 is to be sent, not both.
An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01. An information source may support the use of Service Type Codes other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion.
An information source may support the use of EQ02 - Composite Medical Procedure Identifier at their discretion. The EQ02 allows for a very specific inquiry, such as one based on a procedure code. Additional information such as diagnosis codes can be supplied in the 2100C HI segment and place of service in the 2110C III segment.
If an information source receives a Service Type Code "30" submitted in the 270 EQ01 or a Service Type Code that they do not support, the 2110C EB03 values identified in Section 1.4.7.1 Item #8 must also be returned if they are a covered benefit category at a plan level. Refer to Section 1.4.7 for additional information.
EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110C loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.

TR3 Example:

EQ✱30✱✱FAM~
EQ✱98^34^44^81^A0^A3~

✱

✱

✱

✱

✱

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

Situational

1365

Service Type Code

O 99

1/2

Code identifying the classification of service

SEMANTIC: Position of data in the repeating data element conveys no significance.

SEGMENT SYNTAX: R0102

SITUATIONAL RULE: Required if utilizing a Service Type Code inquiry and EQ02 is not used. If not required by this implementation guide, do not send.

An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01.
An information source may support the use of Service Type Codes from the list other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion. If an information source supports codes in addition to "30", the information source may provide a list of the supported codes from the list below to the information receiver. If no list is provided, an information receiver may transmit the most appropriate code.
If an inquiry is submitted with a Service Type Code from the list other than "30" and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of "30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.4.7 for additional information.
EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110C loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.
Not used if EQ02 is used.

OPERATING RULE REQUIREMENTS: The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule EB.1.0 (URL) requires the information source to support explicit inquiries for all service types (Section 1.3.2.3).

CODE

DEFINITION

Medical Care

Surgical

Consultation

Diagnostic X-Ray

Diagnostic Lab

Radiation Therapy

Anesthesia

Surgical Assistance

Other Medical

Blood Charges

Used Durable Medical Equipment

Durable Medical Equipment Purchase

Ambulatory Service Center Facility

Renal Supplies in the Home

Alternate Method Dialysis

Chronic Renal Disease (CRD) Equipment

Pre-Admission Testing

Durable Medical Equipment Rental

Pneumonia Vaccine

Second Surgical Opinion

Third Surgical Opinion

Social Work

Diagnostic Dental

Periodontics

Restorative

Endodontics

Maxillofacial Prosthetics

Adjunctive Dental Services

Health Benefit Plan Coverage

If only a single category of inquiry can be supported, use this code.

Plan Waiting Period

Chiropractic

Chiropractic Office Visits

Dental Care

Dental Crowns

Dental Accident

Orthodontics

Prosthodontics

Oral Surgery

Routine (Preventive) Dental

Home Health Care

Home Health Prescriptions

Home Health Visits

Hospice

Respite Care

Hospital

Hospital - Inpatient

Hospital - Room and Board

Hospital - Outpatient

Hospital - Emergency Accident

Hospital - Emergency Medical

Hospital - Ambulatory Surgical

Long Term Care

Major Medical

Medically Related Transportation

Air Transportation

Cabulance

Licensed Ambulance

General Benefits

In-vitro Fertilization

MRI/CAT Scan

Donor Procedures

Acupuncture

Newborn Care

Pathology

Smoking Cessation

Well Baby Care

Maternity

Transplants

Audiology Exam

Inhalation Therapy

Diagnostic Medical

Private Duty Nursing

Prosthetic Device

Dialysis

Otological Exam

Chemotherapy

Allergy Testing

Immunizations

Routine Physical

Family Planning

Infertility

Abortion

AIDS

Emergency Services

Cancer

Pharmacy

Free Standing Prescription Drug

Mail Order Prescription Drug

Brand Name Prescription Drug

Generic Prescription Drug

Podiatry

Podiatry - Office Visits

Podiatry - Nursing Home Visits

Professional (Physician)

Anesthesiologist

Professional (Physician) Visit - Office

Professional (Physician) Visit - Inpatient

Professional (Physician) Visit - Outpatient

Professional (Physician) Visit - Nursing Home

Professional (Physician) Visit - Skilled Nursing Facility

Professional (Physician) Visit - Home

Psychiatric

Psychiatric - Room and Board

Psychotherapy

Psychiatric - Inpatient

Psychiatric - Outpatient

Rehabilitation

Rehabilitation - Room and Board

Rehabilitation - Inpatient

Rehabilitation - Outpatient

Occupational Therapy

Physical Medicine

Speech Therapy

Skilled Nursing Care

Skilled Nursing Care - Room and Board

Substance Abuse

Alcoholism

Drug Addiction

Vision (Optometry)

Frames

Routine Exam

Use for Routine Vision Exam only.

Lenses

Nonmedically Necessary Physical

Experimental Drug Therapy

Burn Care

Brand Name Prescription Drug - Formulary

Brand Name Prescription Drug - Non-Formulary

Independent Medical Evaluation

Partial Hospitalization (Psychiatric)

Day Care (Psychiatric)

Cognitive Therapy

Massage Therapy

Pulmonary Rehabilitation

Cardiac Rehabilitation

Pediatric

Nursery

Skin

Orthopedic

Cardiac

Lymphatic

Gastrointestinal

Endocrine

Neurology

Eye

Invasive Procedures

Gynecological

Obstetrical

Obstetrical/Gynecological

Mail Order Prescription Drug: Brand Name

Mail Order Prescription Drug: Generic

Physician Visit - Office: Sick

Physician Visit - Office: Well

Coronary Care

Private Duty Nursing - Inpatient

Private Duty Nursing - Home

Surgical Benefits - Professional (Physician)

Surgical Benefits - Facility

Mental Health Provider - Inpatient

Mental Health Provider - Outpatient

Mental Health Facility - Inpatient

Mental Health Facility - Outpatient

Substance Abuse Facility - Inpatient

Substance Abuse Facility - Outpatient

Screening X-ray

Screening laboratory

Mammogram, High Risk Patient

Mammogram, Low Risk Patient

Flu Vaccination

Eyewear and Eyewear Accessories

Case Management

Dermatology

Durable Medical Equipment

Diabetic Supplies

Generic Prescription Drug - Formulary

Generic Prescription Drug - Non-Formulary

Allergy

Intensive Care

Mental Health

Neonatal Intensive Care

Oncology

Physical Therapy

Pulmonary

Renal

Residential Psychiatric Treatment

Transitional Care

Transitional Nursery Care

Urgent Care

Situational

C003

Composite Medical Procedure Identifier

O 1

To identify a medical procedure by its standardized codes and applicable modifiers

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.

SITUATIONAL RULE: Required if utilizing a Medical Procedure Code inquiry when the information receiver believes that the information source supports this high level of functionality and EQ01 is not used. If not required by this implementation guide, do not send.

An information source may support the use of EQ02 - Composite Medical Procedure Identifier at their discretion. The EQ02 allows for a very specific inquiry, such as one based on a procedure code. Additional information such as diagnosis codes can be supplied in the 2100C HI segment and place of service can be supplied in the 2110C III segment.
If an inquiry is submitted with EQ02 and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of "30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.4.7 for additional information.
Not used if EQ01 is used.

Required

2-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

Use this code to qualify the type of specific Product/Service ID that will be used in EQ02-2.

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Current Procedural Terminology (CPT) Codes

CODE SOURCE: 133: Current Procedural Terminology (CPT) Codes

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

CODE SOURCE: 130: Healthcare Common Procedure Coding System

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE: 513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Mutually Defined

Use this code only for International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS).

CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

Required

2-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Use this number for the product/service ID as identified by the preceding data element (EQ02-1).

Situational

2-3

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high level of functionality. If not required by this implementation guide, do not send.

Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.

Situational

2-4

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a second modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high level of functionality. If not required by this implementation guide, do not send.

Situational

2-5

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a third modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high level of functionality. If not required by this implementation guide, do not send.

Situational

2-6

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a fourth modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high level of functionality. If not required by this implementation guide, do not send.

Not Used

2-7

352

Description

O 1

1/80

Not Used

2-8

234

Product/Service ID

O 1

1/48

Situational

1207

Coverage Level Code

O 1

Code indicating the level of coverage being provided for this insured

SITUATIONAL RULE: Required when the information receiver desires coverage information for an entire family and believes that the information source supports this functionality. If not required by this implementation guide, do not send.

It is at the sole discretion of the information source whether to support this functionality or not. If not supported, information source will process without this data element.

CODE

DEFINITION

FAM

Family

Not Used

1336

Insurance Type Code

O 1

1/3

Situational

C004

Composite Diagnosis Code Pointer

O 1

To identify one or more diagnosis code pointers

X12 COMPOSITE SEMANTIC NOTES:

C004-01 identifies the primary diagnosis code for this service line.
C004-02 identifies the second diagnosis code for this service line.
C004-03 identifies the third diagnosis code for this service line.
C004-04 identifies the fourth diagnosis code for this service line.

SITUATIONAL RULE: Required when a 2100C HI segment is used. If not required by this implementation guide, do not send.

Required

5-1

1328

Diagnosis Code Pointer

M 1

1/2

A pointer to the diagnosis code in the order of importance to this service

This first pointer designates the primary diagnosis for this EQ segment. Remaining diagnosis pointers indicate declining level of importance to the EQ segment. Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.

Situational

5-2

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a second diagnosis related to this EQ segment. If not required by this implementation guide, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.

Situational

5-3

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a third diagnosis related to this EQ segment. If not required by this implementation guide, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.

Situational

5-4

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a fourth diagnosis related to this EQ segment. If not required by this implementation guide, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.

AMT*R - SUBSCRIBER SPEND DOWN AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required if Spend Down amount is being reported. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment only if it is necessary to report a Spend Down amount. Under certain Medicaid programs, individuals must indicate the dollar amount that they wish to apply towards their deductible. These programs require individuals to pay a certain amount towards their health care cost before Medicaid coverage starts.

TR3 Example:

AMT✱R✱37.5~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Spend Down

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Spend Down Amount

Use this monetary amount to specify the dollar amount associated with this inquiry.

Not Used

478

Credit/Debit Flag Code

O 1

AMT*PB - SUBSCRIBER SPEND DOWN TOTAL BILLED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required if Spend Down amount is being reported in a separate 2110C AMT segment and the information source also requires the Spend Down Total Billed Amount. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment only if it is necessary to report the Spend Down Total Billed Amount in addition to the Spend Down Amount. See 2110C Subscriber Spend Down Amount segment for more information about Spend Down.

TR3 Example:

AMT✱PB✱37.5~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Billed Amount

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Spend Down Total Billed Amount

Use this monetary amount to specify the dollar amount associated with this inquiry.

Not Used

478

Credit/Debit Flag Code

O 1

III*ZZ - SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INQUIRY INFORMATION

X12 Name:

Information

X12 Purpose:

To report information

X12 Syntax:

P0102
If either III01 or III02 is present, then the other is required.
L030405
If III03 is present, then at least one of III04 or III05 are required.

Loop:

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver believes the Facility Type information is relevant to the inquiry and the information is available. If not required by this implementation guide, do not send.

TR3 Notes:

Use the III segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment.

TR3 Example:

III✱ZZ✱21~

III

✱

✱

✱

✱

✱

✱

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

✱

✱

✱

Required

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

Use this code to specify the code that is following in the III02 is a Facility Type Code.

CODE

DEFINITION

Mutually Defined

Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of Service Codes for Professional Claims.

Required

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

Use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below; however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here.
01 Pharmacy
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-based Facility
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service

Not Used

1136

Code Category

O 1

Not Used

933

Free-form Message Text

O 1

1/264

Not Used

380

Quantity

O 1

1/15

Not Used

C001

Composite Unit of Measure

O 1

Not Used

752

Surface/Layer/Position Code

O 1

Not Used

752

Surface/Layer/Position Code

O 1

Not Used

752

Surface/Layer/Position Code

O 1

REF - SUBSCRIBER ADDITIONAL INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the subscriber has received a referral or prior authorization number and the information receiver believes the information is relevant to the inquiry (such as for a benefit or procedure that requires a referral or prior authorization) and the information is available. If not required by this implementation guide do not send.

TR3 Notes:

Use this segment when it is necessary to provide a referral or prior authorization number for the benefit being inquired about.

TR3 Example:

REF✱9F✱660415~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number that is following in REF02.

CODE

DEFINITION

Referral Number

Prior Authorization Number

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Prior Authorization or Referral Number

Use this reference number as qualified by the preceding data element (REF01).

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*291 - SUBSCRIBER ELIGIBILITY/BENEFIT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the plan date(s) are different from the date(s) provided in the 2100C loop. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to convey plan dates associated with the information contained in the corresponding EQ segment.
This segment is only to be used to override dates provided in Loop 2100C when the date differs from the date provided in the DTP segment in Loop 2100C. Dates that apply to the entire request must be placed in the DTP segment in Loop 2100C. In order for a date to appear here, there must be a date or a date range in the corresponding 2100C loop.

TR3 Example:

DTP✱291✱D8✱20051031~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

291

Plan

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

Use this code to specify the format of the date(s) or time(s) that follow in the next data element.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

Use this date for the date(s) as qualified by the preceding data elements.

HL - DEPENDENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the patient is a dependent of a member and cannot be uniquely identified to the information source without the member's information in the Subscriber Level 2000C loop. If not required by this implementation guide, do not send.

TR3 Notes:

If a patient is a dependent of a member, but can be uniquely identified to the information source (such as by, but not limited to, a unique Member Identification Number) then the patient is considered the subscriber and is to be identified in the Subscriber Level.
Because the usage of this segment is "Situational", this is not a syntactically required loop. If this loop is used, then this segment is a "Required" segment. See Appendix B for further details on ASC X12 nomenclature.
Use this segment to identify the hierarchical or entity level of information being conveyed. The HL structure allows for the efficient nesting of related occurrences of information. The developers' intent is to clearly identify the relationship of the patient to the subscriber and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient) can be grouped together under the same provider or the information for multiple providers or information receivers can be grouped together for the same payer or information source. See Section 1.3.2 for limitations on the number of occurrences of patients.
An example of the overall structure of the transaction set when used in batch mode is:

Information Source (Loop 2000A)
Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry

TR3 Example:

HL✱4✱3✱23✱0~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

Use this sequentially assigned positive number to identify each specific occurrence of an HL segment within a transaction set. The first HL segment in the transaction must begin with the number 1 and be incremented by 1 for each successive occurrence of the HL segment within that specific transaction set (ST through SE).
An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~
HL*3*2*22*1~
NM1*IL*1*SMITH*ROBERT*B***MI*11122333301~
HL*4*3*23*0~
NM1*03*1*SMITH*MARY*LOU~
Eligibility/Benefit Data
HL*5*2*22*0~
NM1*IL*1*BROWN*JOHN*E***MI*22211333301~
Eligibility/Benefit Data

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Use this code to identify the specific Subscriber to which this level is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

All data that follows this HL segment is associated with the Dependent identified by the level code. This association continues until the next occurrence of an HL segment.

CODE

DEFINITION

Dependent

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

Because of the hierarchical structure, and because no HL level is subordinate to this level, the code value in the HL04 at the Loop 2000D level must always be "0" (zero).

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

TRN*1 - DEPENDENT TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

X12 Set Notes:

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when information receiver or clearinghouse intends to use the TRN segment as a tracing mechanism for the eligibility transaction and the dependent is the patient. If not required by this implementation guide, do not send.

TR3 Notes:

Trace numbers assigned at the dependent level are intended to allow tracing of an eligibility/benefit transaction when the dependent is the patient.
The information receiver may assign one TRN segment in this loop if the dependent is the patient. A clearinghouse may assign one TRN segment in this loop if the dependent is the patient. See Section 1.4.6 Information Linkage.

TR3 Example:

TRN✱1✱98175-012547✱8877281234✱RADIOLOGY~TRN✱1✱109834652831✱WXYZCLEARH✱REALTIME~

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Trace Number

Use this number for the trace or reference number assigned by the information receiver or clearinghouse.

Required

509

Originating Company Identifier

O 1

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this number for the identification number of the company that assigned the trace or reference number specified in the previous data element (TRN02).

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN04 identifies a further subdivision within the organization.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

This information allows the originating company to further identify a specific division or group within that organization that was responsible for assigning the trace or reference number.

NM1*03 - DEPENDENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to identify an entity by name. This NM1 loop is used to identify the dependent of an insured or subscriber.
Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.

TR3 Example:

NM1✱03✱1✱SMITH✱MARY LOU✱R~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Dependent

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

Use this code to indicate whether the entity is an individual person or an organization.

CODE

DEFINITION

Person

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the dependent is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).ORRequired when the dependent is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Last Name (See Section 1.4.8).ORRequired when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Last Name

Use this name for the dependent's last name.
Information sources cannot require dependent's name suffix be sent as a part of the dependent's last name.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the dependent is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).ORRequired when the dependent is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's First Name (See Section 1.4.8).ORRequired when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent First Name

Use this name for the dependent's first name.

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

INDUSTRY NAME: Dependent Middle Name or Initial

Use this name for the dependent's middle name or initial.

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

INDUSTRY NAME: Dependent Name Suffix

Use this for the suffix to an individual's name; e.g., Sr., Jr. or III.

Not Used

Identification Code Qualifier

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - DEPENDENT ADDITIONAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Use this segment when needed to convey identification numbers for the dependent. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100D loop.
Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.

TR3 Example:

REF✱1L✱660415~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number that is following in REF02.
Only one occurrence of each REF01 code value may be used in the 2100D loop.

CODE

DEFINITION

Plan Number

Group or Policy Number

Use this code only if it cannot be determined if the number is a Group Number or a Policy number. Use codes "IG" or "6P" when they can be determined.

Member Identification Number

This code is only for Property and Casualty use when the Property and Casualty Patient Identifier is a Member ID and would be used in an 837 claim in 2010CA REF. This code must not be used for any other purposes.

Group Number

Contract Number

This code is to be used only to identify the provider's contract number of the provider identified in the PRV segment of Loop 2100D. This code is only to be used once the CMS National Provider Identifier has been mandated for use, and must be sent if required in the contract between the Information Receiver identified in Loop 2100B and the Information Source identified in Loop 2100A.

Medical Record Identification Number

Patient Account Number

Health Insurance Claim (HIC) Number

Identification Card Serial Number

Identity Card Number

Use this code when the Identity Card Number is different than the Member Identification Number. This is particularly prevalent in the Medicaid environment.

Issue Number

Insurance Policy Number

MRC

Eligibility Category

CODE SOURCE: 844: Eligibility Category

Plan Network Identification Number

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Agency Claim Number

This code is to only be used when submitting an eligibility request to a Property and Casualty payer. Use this code to identify the Property and Casualty Claim Number associated with the dependent. This code is not a HIPAA requirement as of this writing.

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Dependent Supplemental Identifier

Use this reference number as qualified by the preceding data element (REF01).

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - DEPENDENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N3✱15197 BROADWAY AVENUE✱APT 215~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Dependent Address Line

Use this information for the first line of the address information.

Situational

166

Address Information

O 1

1/55

Address information

INDUSTRY NAME: Dependent Address Line

Use this information for the second line of the address information.

N4 - DEPENDENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Dependent City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

INDUSTRY NAME: Dependent Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

PRV - PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information source is known to process this information in creating a 271 response and the information receiver feels it is necessary to identify a specific provider or to associate a specialty type related to the service identified in the 2110D loop. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

TR3 Notes:

This segment must not be used to identify the information receiver or the information receiver's specialty type, unless the information is different from that sent in the 2100B loop.
If identifying a specific provider, use this segment to convey specific information about a provider's role in the eligibility/benefit being inquired about when the provider is not the information receiver. For example, if the information receiver is a hospital and a referring provider must be identified, this is the segment where the referring provider would be identified.
If identifying a specific provider, this segment contains reference identification numbers, all of which may be used up until the time the National Provider Identifier (NPI) is mandated for use. After the NPI is mandated, only the code for National Provider Identifier may be used.
If identifying a type of specialty associated with the services identified in loop 2110D, use code PXC in PRV02 and the appropriate code in PRV03.
PRV02 qualifies PRV03.

TR3 Example:

PRV✱RF✱EI✱9991234567~PRV✱RF✱PXC✱207Q00000X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Attending

Billing

Consulting

Covering

Hospital

Home Health Care

Laboratory

Other Physician

Pharmacist

Pharmacy

Primary Care Physician

Performing

Rural Health Clinic

Referring

Skilled Nursing Facility

Supervising

Situational

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when the information source is known to process this information in creating a 271 response and the information receiver feels it is necessary to identify a specific provider or to associate a specialty type related to the service identified in the 2110D loop. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

If this segment is used to identify a specific provider and the National Provider ID is mandated for use, code value "HPI" must be used, otherwise one of the other code values may be used.
If this segment is used to identify a type of specialty associated with the services identified in loop 2110D, use code PXC.

CODE

DEFINITION

Servicer

Use this code for the identification number assigned by the information source to be used by the information receiver in health care transactions.

National Council for Prescription Drug Programs Pharmacy Number

CODE SOURCE: 307: National Council for Prescription Drug Programs Pharmacy Number

Employer's Identification Number

HPI

Centers for Medicare and Medicaid Services National Provider Identifier

Required value when identifying a specific provider when the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used.

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Federal Taxpayer's Identification Number

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when PRV02 is used. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Identifier

Use this reference number as qualified by the preceding data element (PRV02).

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

DMG*D8 - DEPENDENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

P0102
If either DMG01 or DMG02 is present, then the other is required.
P1011
If either DMG10 or DMG11 is present, then the other is required.
C1105
If DMG11 is present, then DMG05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the dependent is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).
OR
Required when the dependent is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Date of Birth (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment when needed to convey the birth date or gender demographic information for the dependent.
Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.

TR3 Example:

DMG✱D8✱19430121✱F~

DMG

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Situational

1250

Date Time Period Format Qualifier

O 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when the dependent is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).ORRequired when the dependent is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Date of Birth (See Section 1.4.8).ORRequired when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).If not required by this implementation guide, do not send.

Use this code to indicate the format of the date of birth that follows in DMG02.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

1251

Date Time Period

O 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when the dependent is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).ORRequired when the dependent is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Date of Birth (See Section 1.4.8).ORRequired when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Birth Date

Use this date for the date of birth of the individual.

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

INDUSTRY NAME: Dependent Gender Code

Use this code to indicate the dependent's gender.

CODE

DEFINITION

Female

Male

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

O 10

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

O 1

1/3

Not Used

1271

Industry Code

O 1

1/30

INS*N - DEPENDENT RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit information on insured entities

X12 Syntax:

P1112
If either INS11 or INS12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver believes it is necessary to identify for an Alternate Search Option supported by the Information Source (See Section 1.4.8) the dependent's relationship to the insured and/or the birth sequence of the dependent in the case of multiple births with the same birth date. If not required by this implementation guide, do not send.

TR3 Notes:

Different types of health plans identify patients in different manners depending upon how their eligibility is structured. However, two approaches predominate.

The first approach is to assign each member of the family (and plan) a unique ID number. This number can be used to identify and access that individual's information independent of whether he or she is a child, spouse, or the actual subscriber to the plan. The relationship of this individual to the actual subscriber or contract holder would be one of spouse, child, self, etc.

The second approach is to assign the actual subscriber or contract holder a unique ID number that is entered into the eligibility system. Any related spouse, children, or dependents are identified through the subscriber's ID and have no unique identification number of their own. In this approach, the subscriber would be identified at the Loop 2100C subscriber or insured level and the actual patient (spouse, child, etc.) would be identified at the Loop 2100D dependent level under the subscriber.

TR3 Example:

INS✱N✱01~

INS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

CODE

DEFINITION

Spouse

Child

Other Adult

Not Used

875

Maintenance Type Code

O 1

Not Used

1203

Maintenance Reason Code

O 1

2/3

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Situational

1470

Number

O 1

1/9

A generic number

SITUATIONAL RULE: Required when the information receiver believes it is necessary to identify the birth sequence of the dependent in the case of multiple births with the same birth date supplied in 2100 DMG02 for an Alternate Search Option supported by the Information Source (See Section 1.4.8). If not required by this implementation guide, do not send.

INDUSTRY NAME: Birth Sequence Number

HI - DEPENDENT HEALTH CARE DIAGNOSIS CODE

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Use the HI segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment. The information source must not use information in an HI segment of the 270 transaction in the determination of eligibility or benefits for the dependent if that information cannot be returned in the 271 response.
Use this segment to identify Diagnosis codes as they relate to the information provided in the EQ segments.
Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.

TR3 Example:

HI✱BK:8901✱BF:87200✱BF:5559~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

E codes are Not Used in HI01 except when defined by the claims processor. E codes may be put in any other HI element using BF as the qualifier.
The diagnosis listed in this element is assumed to be the principal diagnosis.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABK

International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

1-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1-4

1251

Date Time Period

O 1

1/35

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

O 1

1/30

Not Used

1-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

2-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

2-4

1251

Date Time Period

O 1

1/35

Not Used

2-5

782

Monetary Amount

O 1

1/18

Not Used

2-6

380

Quantity

O 1

1/15

Not Used

2-7

799

Version Identifier

O 1

1/30

Not Used

2-8

1271

Industry Code

O 1

1/30

Not Used

2-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

3-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

3-4

1251

Date Time Period

O 1

1/35

Not Used

3-5

782

Monetary Amount

O 1

1/18

Not Used

3-6

380

Quantity

O 1

1/15

Not Used

3-7

799

Version Identifier

O 1

1/30

Not Used

3-8

1271

Industry Code

O 1

1/30

Not Used

3-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

4-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

4-4

1251

Date Time Period

O 1

1/35

Not Used

4-5

782

Monetary Amount

O 1

1/18

Not Used

4-6

380

Quantity

O 1

1/15

Not Used

4-7

799

Version Identifier

O 1

1/30

Not Used

4-8

1271

Industry Code

O 1

1/30

Not Used

4-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

5-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

5-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

5-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

5-4

1251

Date Time Period

O 1

1/35

Not Used

5-5

782

Monetary Amount

O 1

1/18

Not Used

5-6

380

Quantity

O 1

1/15

Not Used

5-7

799

Version Identifier

O 1

1/30

Not Used

5-8

1271

Industry Code

O 1

1/30

Not Used

5-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

6-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

6-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

6-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

6-4

1251

Date Time Period

O 1

1/35

Not Used

6-5

782

Monetary Amount

O 1

1/18

Not Used

6-6

380

Quantity

O 1

1/15

Not Used

6-7

799

Version Identifier

O 1

1/30

Not Used

6-8

1271

Industry Code

O 1

1/30

Not Used

6-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

7-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

7-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

7-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

7-4

1251

Date Time Period

O 1

1/35

Not Used

7-5

782

Monetary Amount

O 1

1/18

Not Used

7-6

380

Quantity

O 1

1/15

Not Used

7-7

799

Version Identifier

O 1

1/30

Not Used

7-8

1271

Industry Code

O 1

1/30

Not Used

7-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

8-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

8-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

8-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

8-4

1251

Date Time Period

O 1

1/35

Not Used

8-5

782

Monetary Amount

O 1

1/18

Not Used

8-6

380

Quantity

O 1

1/15

Not Used

8-7

799

Version Identifier

O 1

1/30

Not Used

8-8

1271

Industry Code

O 1

1/30

Not Used

8-9

1073

Yes/No Condition or Response Code

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

DTP - DEPENDENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver wishes to convey the plan date(s) for the dependent in relation to the eligibility/benefit inquiry. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.
OR
Required when utilizing a search option other than either the Primary Search Option or a Required Alternate Search Option identified in section 1.4.8 which requires the ID Card Issue Date. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.

TR3 Notes:

Absence of a Plan date indicates the request is for the date the transaction is processed and the information source is to process the transaction in the same manner as if the processing date was sent.
Use this segment to convey the plan date(s) for the dependent or for the issue date of the dependent's identification card for the information source.
When using code "291" (Plan) at this level, it is implied that these dates apply to all of the Eligibility or Benefit Inquiry (EQ) loops that follow. If there is a need to supply a different Plan date for a specific EQ loop, it must be provided in the DTP segment within the EQ loop and it will only apply to that EQ loop.

TR3 Example:

DTP✱291✱D8✱20051015~

DTP

✱

✱

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

102

Issue

291

Plan

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

Use this code to specify the format of the date(s) or time(s) that follow in the next data element.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

Use this date for the date(s) as qualified by the preceding data elements.

EQ - DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

X12 Name:

Eligibility or Benefit Inquiry

X12 Purpose:

To specify inquired eligibility or benefit information

X12 Syntax:

R0102
At least one of EQ01 or EQ02 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to begin the eligibility/benefit inquiry looping structure.
If the EQ segment is used, either EQ01 - Service Type Code or EQ02 - Composite Medical Procedure Identifier must be used. Only EQ01 or EQ02 is to be sent, not both.

An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01. An information source may support the use of Service Type Codes other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion.

An information source may support the use of EQ02 - Composite Medical Procedure Identifier at their discretion. The EQ02 allows for a very specific inquiry, such as one based on a procedure code. Additional information such as diagnosis codes can be supplied in the 2100D HI segment and place of service in the 2110D III segment.
If an information source receives a Service Type Code "30" submitted in the 270 EQ01 or a Service Type Code that they do not support, the 2110D EB03 values identified in Section 1.4.7.1 Item #8 must also be returned if they are a covered benefit category at a plan level. Refer to Section 1.4.7 for additional information.
EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110D loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.

TR3 Example:

EQ✱98^34^44^81^A0^A3~
EQ✱30~

✱

✱

✱

✱

✱

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

Situational

1365

Service Type Code

O 99

1/2

Code identifying the classification of service

SEMANTIC: Position of data in the repeating data element conveys no significance.

SEGMENT SYNTAX: R0102

SITUATIONAL RULE: Required if utilizing a Service Type Code inquiry and EQ02 is not used. If not required by this implementation guide, do not send.

An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01.
An information source may support the use of Service Type Codes from the list other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion. If an information source supports codes in addition to "30", the information source may provide a list of the supported codes from the list below to the information receiver. If no list is provided, an information receiver may transmit the most appropriate code.
If an inquiry is submitted with a Service Type Code from the list other than "30" and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of "30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.4.7 for additional information.
EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110D loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.
Not used if EQ02 is used.

CODE

DEFINITION

Medical Care

Surgical

Consultation

Diagnostic X-Ray

Diagnostic Lab

Radiation Therapy

Anesthesia

Surgical Assistance

Other Medical

Blood Charges

Used Durable Medical Equipment

Durable Medical Equipment Purchase

Ambulatory Service Center Facility

Renal Supplies in the Home

Alternate Method Dialysis

Chronic Renal Disease (CRD) Equipment

Pre-Admission Testing

Durable Medical Equipment Rental

Pneumonia Vaccine

Second Surgical Opinion

Third Surgical Opinion

Social Work

Diagnostic Dental

Periodontics

Restorative

Endodontics

Maxillofacial Prosthetics

Adjunctive Dental Services

Health Benefit Plan Coverage

If only a single category of inquiry can be supported, use this code.

Plan Waiting Period

Chiropractic

Chiropractic Office Visits

Dental Care

Dental Crowns

Dental Accident

Orthodontics

Prosthodontics

Oral Surgery

Routine (Preventive) Dental

Home Health Care

Home Health Prescriptions

Home Health Visits

Hospice

Respite Care

Hospital

Hospital - Inpatient

Hospital - Room and Board

Hospital - Outpatient

Hospital - Emergency Accident

Hospital - Emergency Medical

Hospital - Ambulatory Surgical

Long Term Care

Major Medical

Medically Related Transportation

Air Transportation

Cabulance

Licensed Ambulance

General Benefits

In-vitro Fertilization

MRI/CAT Scan

Donor Procedures

Acupuncture

Newborn Care

Pathology

Smoking Cessation

Well Baby Care

Maternity

Transplants

Audiology Exam

Inhalation Therapy

Diagnostic Medical

Private Duty Nursing

Prosthetic Device

Dialysis

Otological Exam

Chemotherapy

Allergy Testing

Immunizations

Routine Physical

Family Planning

Infertility

Abortion

AIDS

Emergency Services

Cancer

Pharmacy

Free Standing Prescription Drug

Mail Order Prescription Drug

Brand Name Prescription Drug

Generic Prescription Drug

Podiatry

Podiatry - Office Visits

Podiatry - Nursing Home Visits

Professional (Physician)

Anesthesiologist

Professional (Physician) Visit - Office

Professional (Physician) Visit - Inpatient

Professional (Physician) Visit - Outpatient

Professional (Physician) Visit - Nursing Home

Professional (Physician) Visit - Skilled Nursing Facility

Professional (Physician) Visit - Home

Psychiatric

Psychiatric - Room and Board

Psychotherapy

Psychiatric - Inpatient

Psychiatric - Outpatient

Rehabilitation

Rehabilitation - Room and Board

Rehabilitation - Inpatient

Rehabilitation - Outpatient

Occupational Therapy

Physical Medicine

Speech Therapy

Skilled Nursing Care

Skilled Nursing Care - Room and Board

Substance Abuse

Alcoholism

Drug Addiction

Vision (Optometry)

Frames

Routine Exam

Use for Routine Vision Exam only.

Lenses

Nonmedically Necessary Physical

Experimental Drug Therapy

Burn Care

Brand Name Prescription Drug - Formulary

Brand Name Prescription Drug - Non-Formulary

Independent Medical Evaluation

Partial Hospitalization (Psychiatric)

Day Care (Psychiatric)

Cognitive Therapy

Massage Therapy

Pulmonary Rehabilitation

Cardiac Rehabilitation

Pediatric

Nursery

Skin

Orthopedic

Cardiac

Lymphatic

Gastrointestinal

Endocrine

Neurology

Eye

Invasive Procedures

Gynecological

Obstetrical

Obstetrical/Gynecological

Mail Order Prescription Drug: Brand Name

Mail Order Prescription Drug: Generic

Physician Visit - Office: Sick

Physician Visit - Office: Well

Coronary Care

Private Duty Nursing - Inpatient

Private Duty Nursing - Home

Surgical Benefits - Professional (Physician)

Surgical Benefits - Facility

Mental Health Provider - Inpatient

Mental Health Provider - Outpatient

Mental Health Facility - Inpatient

Mental Health Facility - Outpatient

Substance Abuse Facility - Inpatient

Substance Abuse Facility - Outpatient

Screening X-ray

Screening laboratory

Mammogram, High Risk Patient

Mammogram, Low Risk Patient

Flu Vaccination

Eyewear and Eyewear Accessories

Case Management

Dermatology

Durable Medical Equipment

Diabetic Supplies

Generic Prescription Drug - Formulary

Generic Prescription Drug - Non-Formulary

Allergy

Intensive Care

Mental Health

Neonatal Intensive Care

Oncology

Physical Therapy

Pulmonary

Renal

Residential Psychiatric Treatment

Transitional Care

Transitional Nursery Care

Urgent Care

Situational

C003

Composite Medical Procedure Identifier

O 1

To identify a medical procedure by its standardized codes and applicable modifiers

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.

An information source may support the use of EQ02 - Composite Medical Procedure Identifier at their discretion. The EQ02 allows for a very specific inquiry, such as one based on a procedure code. Additional information such as diagnosis codes can be supplied in the 2100D HI segment and place of service can be supplied in the 2110D III segment.
If an inquiry is submitted with EQ02 and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of "30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.4.7 for additional information.
Not used if EQ01 is used.

Required

2-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

Use this code to qualify the type of specific Product/Service ID that will be used in EQ02-2.

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Current Procedural Terminology (CPT) Codes

CODE SOURCE: 133: Current Procedural Terminology (CPT) Codes

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

CODE SOURCE: 130: Healthcare Common Procedure Coding System

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE: 513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Mutually Defined

Required

2-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Use this number for the product/service ID as identified by the preceding data element (EQ02-1).

Situational

2-3

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

Situational

2-4

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

Situational

2-5

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

Situational

2-6

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

Not Used

2-7

352

Description

O 1

1/80

Not Used

2-8

234

Product/Service ID

O 1

1/48

Not Used

1207

Coverage Level Code

O 1

Not Used

1336

Insurance Type Code

O 1

1/3

Situational

C004

Composite Diagnosis Code Pointer

O 1

To identify one or more diagnosis code pointers

X12 COMPOSITE SEMANTIC NOTES:

C004-01 identifies the primary diagnosis code for this service line.
C004-02 identifies the second diagnosis code for this service line.
C004-03 identifies the third diagnosis code for this service line.
C004-04 identifies the fourth diagnosis code for this service line.

SITUATIONAL RULE: Required when a 2100D HI segment is used. If not required by this implementation guide, do not send.

Required

5-1

1328

Diagnosis Code Pointer

M 1

1/2

A pointer to the diagnosis code in the order of importance to this service

Situational

5-2

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a second diagnosis related to this EQ segment. If not required by this implementation guide, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.

Situational

5-3

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a third diagnosis related to this EQ segment. If not required by this implementation guide, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.

Situational

5-4

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a fourth diagnosis related to this EQ segment. If not required by this implementation guide, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.

III*ZZ - DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INQUIRY INFORMATION

X12 Name:

Information

X12 Purpose:

To report information

X12 Syntax:

P0102
If either III01 or III02 is present, then the other is required.
L030405
If III03 is present, then at least one of III04 or III05 are required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information receiver believes the Facility Type information is relevant to the inquiry and the information is available. If not required by this implementation guide, do not send.

TR3 Notes:

Use the III segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment.

TR3 Example:

III✱ZZ✱21~

III

✱

✱

✱

✱

✱

✱

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

✱

✱

✱

Required

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

Use this code to specify the code that is following in the III02 is a Facility Type Code.

CODE

DEFINITION

Mutually Defined

Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of Service Codes for Professional Claims.

Required

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

Not Used

1136

Code Category

O 1

Not Used

933

Free-form Message Text

O 1

1/264

Not Used

380

Quantity

O 1

1/15

Not Used

C001

Composite Unit of Measure

O 1

Not Used

752

Surface/Layer/Position Code

O 1

Not Used

752

Surface/Layer/Position Code

O 1

Not Used

752

Surface/Layer/Position Code

O 1

REF - DEPENDENT ADDITIONAL INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the dependent has received a referral or prior authorization number and the information receiver believes the information is relevant to the inquiry (such as for a benefit or procedure that requires a referral or prior authorization) and the information is available. If not required by this implementation guide do not send.

TR3 Notes:

Use this segment when it is necessary to provide a referral or prior authorization number for the benefit being inquired about.

TR3 Example:

REF✱9F✱660415~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number that is following in REF02.

CODE

DEFINITION

Referral Number

Prior Authorization Number

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Prior Authorization or Referral Number

Use this reference number as qualified by the preceding data element (REF01).

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*291 - DEPENDENT ELIGIBILITY/BENEFIT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the plan date(s) are different from the date(s) provided in the 2100C loop. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to convey plan dates associated with the information contained in the corresponding EQ segment.
This segment is only to be used to override dates provided in Loop 2100D when the date differs from the date provided in the DTP segment in Loop 2100D. Dates that apply to the entire request must be placed in the DTP segment in Loop 2100D. In order for a date to appear here, there must be a date or a date range in the corresponding 2100D loop.

TR3 Example:

DTP✱291✱D8✱20051031~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

291

Plan

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

Use this code to specify the format of the date(s) or time(s) that follow in the next data element.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

Use this date for the date(s) as qualified by the preceding data elements.

SE - TRANSACTION SET TRAILER

X12 Name:

Transaction Set Trailer

X12 Purpose:

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

X12 Comments:

SE is the last segment of each transaction set.

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to mark the end of a transaction set and provide control information on the total number of segments included in the transaction set.

TR3 Example:

SE✱41✱0001~

✱

✱

Required

Number of Included Segments

M 1

1/10

Total number of segments included in a transaction set including ST and SE segments

INDUSTRY NAME: Transaction Segment Count

Use this number to indicate the total number of segments included in the transaction set inclusive of the ST and SE segments.

Required

329

Transaction Set Control Number

M 1

4/9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example "0001", and increment from there. This number must be unique within a specific functional group (segments GS through GE) and interchange, but can repeat in other groups and interchanges.

GE - FUNCTIONAL GROUP TRAILER

X12 Name:

Functional Group Trailer

X12 Purpose:

To indicate the end of a functional group and to provide control information

X12 Comments:

The use of identical data interchange control numbers in the associated functional group header and trailer is designed to maximize functional group integrity. The control number is the same as that used in the corresponding header.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GE✱1✱1~

✱

Number of
TS Included

✱

Required

Number of Transaction Sets Included

M 1

1/6

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

SEMANTIC: The data interchange control number GE02 in this trailer must be identical to the same data element in the associated functional group header, GS06.

IEA - INTERCHANGE CONTROL TRAILER

X12 Name:

Interchange Control Trailer

X12 Purpose:

To define the end of an interchange of zero or more functional groups and interchange-related control segments

Segment Usage:

Required

Segment Repeat:

TR3 Example:

IEA✱1✱000000905~

IEA

✱

I16

Num of Incl
Funct Group

✱

Required

I16

Number of Included Functional Groups

M 1

1/5

A count of the number of functional groups included in an interchange

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

271 Response Transaction Set Listing

Usage

Repeats

ISA INTERCHANGE CONTROL HEADER

Required

1
GS*HB FUNCTIONAL GROUP HEADER

Required

1
ST*271 TRANSACTION SET HEADER

Required

1
BHT*0022 BEGINNING OF HIERARCHICAL TRANSACTION

Required

1
Loop 2000A - INFORMATION SOURCE LEVEL

Required

>1
- HL INFORMATION SOURCE LEVEL
  
  Required
  
  1
- AAA REQUEST VALIDATION
  
  Situational
  
  9
- Loop 2100A - INFORMATION SOURCE NAME
  
  Required
  
  1
  - NM1 INFORMATION SOURCE NAME
    
    Required
    
    1
  - PER*IC INFORMATION SOURCE CONTACT INFORMATION
    
    Situational
    
    3
  - AAA REQUEST VALIDATION
    
    Situational
    
    9
Loop 2000B - INFORMATION RECEIVER LEVEL

Situational

>1
- HL INFORMATION RECEIVER LEVEL
  
  Required
  
  1
- Loop 2100B - INFORMATION RECEIVER NAME
  
  Required
  
  1
  - NM1 INFORMATION RECEIVER NAME
    
    Required
    
    1
  - REF INFORMATION RECEIVER ADDITIONAL IDENTIFICATION
    
    Situational
    
    9
  - N3 INFORMATION RECEIVER ADDRESS
    
    Situational
    
    1
  - N4 INFORMATION RECEIVER CITY, STATE, ZIP CODE
    
    Situational
    
    1
  - AAA INFORMATION RECEIVER REQUEST VALIDATION
    
    Situational
    
    9
  - PRV INFORMATION RECEIVER PROVIDER INFORMATION
    
    Situational
    
    1
Loop 2000C - SUBSCRIBER LEVEL

Situational

>1
- HL SUBSCRIBER LEVEL
  
  Required
  
  1
- TRN SUBSCRIBER TRACE NUMBER
  
  Situational
  
  3
- Loop 2100C - SUBSCRIBER NAME
  
  Required
  
  1
  - NM1*IL SUBSCRIBER NAME
    
    Required
    
    1
  - REF SUBSCRIBER ADDITIONAL IDENTIFICATION
    
    Situational
    
    9
  - N3 SUBSCRIBER ADDRESS
    
    Situational
    
    1
  - N4 SUBSCRIBER CITY, STATE, ZIP CODE
    
    Situational
    
    1
  - AAA SUBSCRIBER REQUEST VALIDATION
    
    Situational
    
    9
  - PRV PROVIDER INFORMATION
    
    Situational
    
    1
  - DMG*D8 SUBSCRIBER DEMOGRAPHIC INFORMATION
    
    Situational
    
    1
  - INS*Y SUBSCRIBER RELATIONSHIP
    
    Situational
    
    1
  - HI SUBSCRIBER HEALTH CARE DIAGNOSIS CODE
    
    Situational
    
    1
  - DTP SUBSCRIBER DATE
    
    Situational
    
    9
  - MPI SUBSCRIBER MILITARY PERSONNEL INFORMATION
    
    Situational
    
    1
  - Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION
    
    Situational
    
    >1
    - EB SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION
      
      Required
      
      1
    - HSD HEALTH CARE SERVICES DELIVERY
      
      Situational
      
      9
    - REF SUBSCRIBER ADDITIONAL IDENTIFICATION
      
      Situational
      
      9
    - DTP SUBSCRIBER ELIGIBILITY/BENEFIT DATE
      
      Situational
      
      20
    - AAA SUBSCRIBER REQUEST VALIDATION
      
      Situational
      
      9
    - MSG MESSAGE TEXT
      
      Situational
      
      10
    - Loop 2115C - SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION
      
      Situational
      
      10
      - III SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION
        
        Required
        
        1
    - LS LOOP HEADER
      
      Situational
      
      1
    - Loop 2120C - SUBSCRIBER BENEFIT RELATED ENTITY NAME
      
      Situational
      
      23
      - NM1 SUBSCRIBER BENEFIT RELATED ENTITY NAME
        
        Required
        
        1
      - N3 SUBSCRIBER BENEFIT RELATED ENTITY ADDRESS
        
        Situational
        
        1
      - N4 SUBSCRIBER BENEFIT RELATED ENTITY CITY, STATE, ZIP CODE
        
        Situational
        
        1
      - PER*IC SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION
        
        Situational
        
        3
      - PRV SUBSCRIBER BENEFIT RELATED PROVIDER INFORMATION
        
        Situational
        
        1
    - LE LOOP TRAILER
      
      Situational
      
      1
Loop 2000D - DEPENDENT LEVEL

Situational

>1
- HL DEPENDENT LEVEL
  
  Required
  
  1
- TRN DEPENDENT TRACE NUMBER
  
  Situational
  
  3
- Loop 2100D - DEPENDENT NAME
  
  Required
  
  1
  - NM1*03 DEPENDENT NAME
    
    Required
    
    1
  - REF DEPENDENT ADDITIONAL IDENTIFICATION
    
    Situational
    
    9
  - N3 DEPENDENT ADDRESS
    
    Situational
    
    1
  - N4 DEPENDENT CITY, STATE, ZIP CODE
    
    Situational
    
    1
  - AAA DEPENDENT REQUEST VALIDATION
    
    Situational
    
    9
  - PRV PROVIDER INFORMATION
    
    Situational
    
    1
  - DMG*D8 DEPENDENT DEMOGRAPHIC INFORMATION
    
    Situational
    
    1
  - INS*N DEPENDENT RELATIONSHIP
    
    Situational
    
    1
  - HI DEPENDENT HEALTH CARE DIAGNOSIS CODE
    
    Situational
    
    1
  - DTP DEPENDENT DATE
    
    Situational
    
    9
  - MPI DEPENDENT MILITARY PERSONNEL INFORMATION
    
    Situational
    
    1
  - Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION
    
    Situational
    
    >1
    - EB DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION
      
      Required
      
      1
    - HSD HEALTH CARE SERVICES DELIVERY
      
      Situational
      
      9
    - REF DEPENDENT ADDITIONAL IDENTIFICATION
      
      Situational
      
      9
    - DTP DEPENDENT ELIGIBILITY/BENEFIT DATE
      
      Situational
      
      20
    - AAA DEPENDENT REQUEST VALIDATION
      
      Situational
      
      9
    - MSG MESSAGE TEXT
      
      Situational
      
      10
    - Loop 2115D - DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION
      
      Situational
      
      10
      - III DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION
        
        Required
        
        1
    - LS LOOP HEADER
      
      Situational
      
      1
    - Loop 2120D - DEPENDENT BENEFIT RELATED ENTITY NAME
      
      Situational
      
      23
      - NM1 DEPENDENT BENEFIT RELATED ENTITY NAME
        
        Required
        
        1
      - N3 DEPENDENT BENEFIT RELATED ENTITY ADDRESS
        
        Situational
        
        1
      - N4 DEPENDENT BENEFIT RELATED ENTITY CITY, STATE, ZIP CODE
        
        Situational
        
        1
      - PER*IC DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION
        
        Situational
        
        3
      - PRV DEPENDENT BENEFIT RELATED PROVIDER INFORMATION
        
        Situational
        
        1
    - LE LOOP TRAILER
      
      Situational
      
      1
SE TRANSACTION SET TRAILER

Required

1
GE FUNCTIONAL GROUP TRAILER

Required

1
IEA INTERCHANGE CONTROL TRAILER

Required

1

ISA - INTERCHANGE CONTROL HEADER

X12 Name:

Interchange Control Header

X12 Purpose:

To start and identify an interchange of zero or more functional groups and interchange-related control segments

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

All positions within each of the data elements must be filled.
For compliant implementations under this implementation guide, ISA13, the interchange Control Number, must be a positive unsigned number. Therefore, the ISA segment can be considered a fixed record length segment.
The first element separator defines the element separator to be used through the entire interchange.
The ISA segment terminator defines the segment terminator used throughout the entire interchange.
Spaces in the example interchanges are represented by "." for clarity.

TR3 Example:

ISA✱00✱..........✱01✱SECRET....✱ZZ✱SUBMITTERS.ID..✱ZZ✱RECEIVERS.ID...✱030101✱1253✱^✱00501✱000000905✱0✱T✱:~

ISA

✱

I01

Author Info
Qualifier

✱

✱

✱

✱

✱

Interchange
Sender ID

✱

✱

Interchange
Receiver ID

✱

✱

✱

✱

Inter Ctrl
Version Num

✱

✱

✱

✱

Component
Elem Sepera

Required

I01

Authorization Information Qualifier

M 1

Code identifying the type of information in the Authorization Information

CODE

DEFINITION

No Authorization Information Present (No Meaningful Information in I02)

Additional Data Identification

Required

I02

Authorization Information

M 1

Required

I03

Security Information Qualifier

M 1

Code identifying the type of information in the Security Information

CODE

DEFINITION

No Security Information Present (No Meaningful Information in I04)

Password

Required

I04

Security Information

M 1

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

Required

I05

Interchange ID Qualifier

M 1

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

This ID qualifies the Sender in ISA06.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I06

Interchange Sender ID

M 1

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

Required

I05

Interchange ID Qualifier

M 1

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

This ID qualifies the Receiver in ISA08.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I07

Interchange Receiver ID

M 1

Required

I08

Interchange Date

M 1

Date of the interchange

The date format is YYMMDD.

Required

I09

Interchange Time

M 1

Time of the interchange

The time format is HHMM.

Required

I65

Repetition Separator

M 1

Required

I11

Interchange Control Version Number

M 1

Code specifying the version number of the interchange control segments

CODE

DEFINITION

00501

Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02.
Must be a positive unsigned number and must be identical to the value in IEA02.

Required

I13

Acknowledgment Requested

M 1

Code indicating sender's request for an interchange acknowledgment

See Section B.1.1.5.1 for interchange acknowledgment information.

CODE

DEFINITION

No Interchange Acknowledgment Requested

Interchange Acknowledgment Requested (TA1)

Required

I14

Interchange Usage Indicator

M 1

Code indicating whether data enclosed by this interchange envelope is test, production or information

CODE

DEFINITION

Production Data

Test Data

Required

I15

Component Element Separator

M 1

GS*HB - FUNCTIONAL GROUP HEADER

X12 Name:

Functional Group Header

X12 Purpose:

To indicate the beginning of a functional group and to provide control information

X12 Comments:

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GS✱XX✱SENDER CODE✱RECEIVER CODE✱20071231✱0802✱1✱X✱005010X000~

✱

✱

Application
Send's Code

2/15

✱

124

Application
Rec's Code

✱

✱

✱

✱

Responsible
Agency Code

✱

Required

479

Functional Identifier Code

M 1

Code identifying a group of application related transaction sets

CODE

DEFINITION

Eligibility, Coverage or Benefit Information (271)HS Eligibility, Coverage or Benefit Inquiry (270)

Required

142

Application Sender's Code

M 1

2/15

Code identifying party sending transmission; codes agreed to by trading partners

Use this code to identify the unit sending the information.

Required

124

Application Receiver's Code

M 1

2/15

Code identifying party receiving transmission; codes agreed to by trading partners

Use this code to identify the unit receiving the information.

Required

373

Date

M 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEMANTIC: GS04 is the group date.

Use this date for the functional group creation date.

Required

337

Time

M 1

4/8

SEMANTIC: GS05 is the group time.

Use this time for the creation time. The recommended format is HHMM.

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

SEMANTIC: The data interchange control number GS06 in this header must be identical to the same data element in the associated functional group trailer, GE02.

Required

455

Responsible Agency Code

M 1

1/2

Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

CODE

DEFINITION

Accredited Standards Committee X12

Required

480

Version / Release / Industry Identifier Code

M 1

1/12

INDUSTRY NAME: Version, Release, or Industry Identifier Code

CODE SOURCE 881:Version / Release / Industry Identifier Code

CODE

DEFINITION

005010X279A1

Health Care Eligibility Benefit Inquiry and Response

ST*271 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

To indicate the start of a transaction set and to assign a control number

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this control segment to mark the start of a transaction set. One ST segment exists for every transaction set that occurs within a functional group.

TR3 Example:

ST✱271✱0001✱005010X279A1~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

Code uniquely identifying a Transaction Set

CODE

DEFINITION

271

Eligibility, Coverage or Benefit Information

Required

329

Transaction Set Control Number

M 1

4/9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example "0001", and increment from there.

Required

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

This element must be populated with 005010X279A1.
This element contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST/SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.

CODE

DEFINITION

005010X279A1

Health Care Eligibility Benefit Inquiry and Response

BHT*0022 - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this required segment to start the transaction set and indicate the sequence of the hierarchical levels of information that will follow in Table 2.

TR3 Example:

BHT✱0022✱11✱199800114000001✱19980101✱1401~

BHT

✱

✱

✱

✱

✱

✱

Transaction
Type Code

Loop 2000A - INFORMATION SOURCE LEVEL

Required

1005

Hierarchical Structure Code

M 1

Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set

CODE

DEFINITION

0022

Information Source, Information Receiver, Subscriber, Dependent

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Confirmation

Use this code only to acknowledge the successful cancellation of a 270 transaction that was received with a BHT02 value of "01" Cancellation.

Response

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.

SITUATIONAL RULE: Required when the transaction is used in Real Time (See Section 1.4.3). If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Submitter Transaction Identifier

This information may be sent at the creator of the 271's discretion if using the transaction in a Batch mode and a Submitter Transaction Identifier was received in the 270 transaction BHT03, otherwise this is not used. Due to the nature of batch transaction processing, the receiver of the 270 transaction (whether it is a clearinghouse or information source) may or may not be able to return the 270 BHT03 value in the 271 BHT03. See Section 1.4.6 Information Linkage for additional information and requirements.
This element is to be used to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. This identifier is to be the identifier received in the BHT03 of the corresponding 270 transaction. This identifier is not to be passed through the complete life of the transaction, rather replaced with the identifier received in the 270.

Required

373

Date

O 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEMANTIC: BHT04 is the date the transaction was created within the business application system.

INDUSTRY NAME: Transaction Set Creation Date

Use this date for the date the transaction set was generated.

Required

337

Time

O 1

4/8

SEMANTIC: BHT05 is the time the transaction was created within the business application system.

INDUSTRY NAME: Transaction Set Creation Time

Use this time for the time the transaction set was generated.

Not Used

640

Transaction Type Code

O 1

HL - INFORMATION SOURCE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to identify the hierarchical or entity level of information being conveyed. The HL structure allows for the efficient nesting of related occurrences of information. The developers' intent is to clearly identify the relationship of the patient to the subscriber and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient) can be grouped together under the same provider or the information for multiple providers or information receivers can be grouped together for the same payer or information source. See Section 1.3.2 for limitations on the number of occurrences of patients.
An example of the overall structure of the transaction set when used in batch mode is:

Information Source Loop 2000A
Information Receiver Loop 2000B
Subscriber Loop 2000C
Dependent Loop 2000D
Eligibility or Benefit Information
Subscriber Loop 2000C
Eligibility or Benefit Information
Dependent Loop 2000D
Eligibility or Benefit Information

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

Use the sequentially assigned positive number to identify each specific occurrence of an HL segment within a transaction set. The first HL segment in the transaction must begin with the number 1 and be incremented by 1 for each successive occurrence of the HL segment within that specific transaction set (ST through SE).
An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~

Not Used

734

Hierarchical Parent ID Number

O 1

1/12

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

All data that follows this HL segment is associated with the Information Source identified by the level code. This association continues until the next occurrence of an HL segment.

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

Use this code to indicate whether there are additional hierarchical levels subordinate to this Information Source.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

AAA - REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

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

Loop:

Loop 2000A - INFORMATION SOURCE LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request could not be processed at a system or application level based on the entities identified in ISA06, ISA08, GS02 or GS03 and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.

TR3 Notes:

Use of this segment at this location in the HL is to identify reasons why a request cannot be processed based on the entities identified in ISA06, ISA08, GS02 or GS03.

TR3 Example:

AAA✱Y✱✱42✱Y~

AAA

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

Not Used

559

Agency Qualifier Code

O 1

Required

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

Use this code to indicate the reason why the transaction was unable to be processed successfully by the entity identified in either ISA08 or GS03.

CODE

DEFINITION

Authorized Quantity Exceeded

Use this code to indicate that the transaction exceeds the number of patient requests allowed by the entity identified in either ISA08 or GS03. See section 1.4.3 Batch and Real Time for more information regarding the number of patient requests allowed in a transaction. This is not to be used to indicate that the number of patient requests exceeds the number allowed by the Information Source identified in Loop 2100A.

Authorization/Access Restrictions

Use this code to indicate that the entity identified in GS02 is not authorized to submit 270 transactions to the entity identified in either ISA08 or GS03. This is not to be used to indicate Authorization/Access Restrictions as related to the Information Source Identified in Loop 2100A.

Unable to Respond at Current Time

Use this code to indicate that the entity identified in either ISA08 or GS03 is unable to process the transaction at the current time. This indicates that there is a problem within the systems of the entity identified in either ISA08 or GS03 and is not related to any problem with the Information Source Identified in Loop 2100A.

Invalid Participant Identification

Use this code to indicate that the value in either GS02 or GS03 is invalid.

Required

889

Follow-up Action Code

O 1

Code identifying follow-up actions allowed

Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Please Resubmit Original Transaction

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

NM1 - INFORMATION SOURCE NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to identify an entity by name and identification number. This NM1 loop is used to identify the eligibility or benefit information source (e.g., insurance company, HMO, IPA, employer).

TR3 Example:

NM1✱PR✱2✱ACE INSURANCE COMPANY✱✱✱✱✱PI✱87728~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Third-Party Administrator

Employer

Gateway Provider

Plan Sponsor

Payer

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

Use this code to indicate whether the entity is an individual person or an organization.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Information Source Last or Organization Name

Use this name for the organization name if NM102 is "2". Otherwise, this will be the individual's last name.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = "1" (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

INDUSTRY NAME: Information Source Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

INDUSTRY NAME: Information Source Name Suffix

Required

Identification Code Qualifier

O 1

1/2

Code designating the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Employer's Identification Number

Electronic Transmitter Identification Number (ETIN)

Federal Taxpayer's Identification Number

National Association of Insurance Commissioners (NAIC) Identification

Payor Identification

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Use this code for the reference number as qualified by the preceding data element (NM108).

INDUSTRY NAME: Information Source Primary Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PER*IC - INFORMATION SOURCE CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Source desires to advise the Information Receiver on how to contact the Information Source about this eligibility response. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

If this segment is used, at a minimum either PER02 must be used or PER03 and PER04 must be used. It is recommended that at least PER02, PER03 and PER04 are sent if this segment is used.
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.

TR3 Example:

PER✱IC✱MEMBER SERVICES✱TE✱8005551654✱FX✱2128769304~
PER✱IC✱BILLING DEPT✱TE✱2128763654✱EX✱2104✱FX✱2128769304~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

1/20

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

Use this code to specify the type of person or group to which the contact number applies.

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when it is necessary to identify an individual or other contact point to discuss information related to this transaction. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Contact Name

Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1).

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when a contact communication number, e-mail or Web address is to be transmitted. If not required by this implementation guide, do not send.

Use this code to specify what type of communication number is following.

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not present or when a contact number, e-mail or Web address is to be sent in addition to the contact name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Communication Number

Use this for the communication number or URL as qualified by the preceding data element.
The format for US domestic phone numbers is:
AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a second communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

Use this code to specify what type of communication number is following.

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a second communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Communication Number

The format for US domestic phone numbers is:
AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number
Use this for the communication number or URL as qualified by the preceding data element.

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a third communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

Use this code to specify what type of communication number is following.

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a third communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Source Communication Number

The format for US domestic phone numbers is:
AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number
Use this for the communication number or URL as qualified by the preceding data element.

Not Used

443

Contact Inquiry Reference

O 1

1/20

AAA - REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request could not be processed at a system or application level when specifically related to the information source data contained in the original 270 transaction's information source name loop (Loop 2100A) or to indicate that the information source itself is experiencing system problems and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to indicate problems in processing the transaction specifically related to the information source data contained in the original 270 transaction's information source name loop (Loop 2100A) or to indicate that the information source itself is experiencing system problems.

TR3 Example:

AAA✱Y✱✱42✱Y~

AAA

✱

Loop 2000B - INFORMATION RECEIVER LEVEL

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

Not Used

559

Agency Qualifier Code

O 1

Required

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.

CODE

DEFINITION

Authorized Quantity Exceeded

Use this code to indicate that the transaction exceeds the number of patient requests allowed by the Information Source identified in Loop 2100A. See section 1.4.3 Batch and Real Time for more information regarding the number of patient requests allowed in a transaction.

Authorization/Access Restrictions

Use this code to indicate that the entity identified in ISA06 or GS02 is not authorized to submit 270 transactions to the Information Source Identified in Loop 2100A.

Unable to Respond at Current Time

Use this code to indicate that Information Source Identified in Loop 2100A is unable to process the transaction at the current time. This indicates that there is a problem within the Information Source's system.

Invalid Participant Identification

Use this code to indicate that Information Source Identified in Loop 2100A is invalid. If the transaction is processed by a clearing house, VAN, etc., use this code to indicate that the Information Source Identified in Loop 2100A is not a valid identifier for Information Sources the clearing house, VAN, etc. have access to. If the transaction is sent directly to the Information Source, use this code to indicate that the Information Source Identified in Loop 2100A is not a valid identifier.

No Response received - Transaction Terminated

Use this code only if the transaction is processed by a clearing house, VAN, etc. Use this code to indicate that the transaction was sent to the Information Source identified in Loop 2100A however no response was received in the expected time frame.

This code must not be used by the Information Source identified in Loop 2100A.

Payer Name or Identifier Missing

Use this code to indicate that either the name or identifier for Information Source Identified in Loop 2100A is missing.

Required

889

Follow-up Action Code

O 1

Code identifying follow-up actions allowed

Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Please Resubmit Original Transaction

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

Please Wait 10 Days and Resubmit

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

HL - INFORMATION RECEIVER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required unless the 271 response contains an AAA segment in loop 2000A or 2100A. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

TR3 Notes:

Use this segment to identify the hierarchical or entity level of information being conveyed. The HL structure allows for the efficient nesting of related occurrences of information. The developers' intent is to clearly identify the relationship of the patient to the subscriber and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient) can be grouped together under the same provider or the information for multiple providers or information receivers can be grouped together for the same payer or information source. See Section 1.3.2 for limitations on the number of occurrences of patients.
An example of the overall structure of the transaction set when used in batch mode is:

Information Source Loop 2000A
Information Receiver Loop 2000B
Subscriber Loop 2000C
Dependent Loop 2000D
Eligibility or Benefit Information
Subscriber Loop 2000C
Eligibility or Benefit Information
Dependent Loop 2000D
Eligibility or Benefit Information

TR3 Example:

HL✱2✱1✱21✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

Use the sequentially assigned positive number to identify each specific occurrence of an HL segment within a transaction set. The first HL segment in the transaction must begin with the number 1 and be incremented by 1 for each successive occurrence of the HL segment within that specific transaction set (ST through SE).
An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Use this ID number to identify the specific Information Source to which this Information Receiver is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

All data that follows this HL segment is associated with the Information Receiver identified by the level code. This association continues until the next occurrence of an HL segment.

CODE

DEFINITION

Information Receiver

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

Use this code to indicate whether there are additional hierarchical levels subordinate to the current hierarchical level.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 - INFORMATION RECEIVER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

TR3 Example:

NM1✱1P✱1✱JONES✱MARCUS✱✱✱MD✱34✱111223333~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Provider

Third-Party Administrator

Employer

Hospital

Facility

Gateway Provider

Plan Sponsor

Payer

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

Use this code to indicate whether the entity is an individual person or an organization.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when this information was used from the 270 transaction to identify the Information Receiver. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Information Receiver Last or Organization Name

Use this name for the organization name if the entity type qualifier is a non-person entity. Otherwise, this will be the individual's last name.

Situational

1036

Name First

O 1

1/35

Individual first name

INDUSTRY NAME: Information Receiver First Name

Use this name only if NM102 is "1".

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

INDUSTRY NAME: Information Receiver Middle Name

Use this name only if NM102 is "1".

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

INDUSTRY NAME: Information Receiver Name Suffix

Use name suffix only if NM102 is "1"; e.g., Sr., Jr., or III.

Required

Identification Code Qualifier

O 1

1/2

Code designating the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Employer's Identification Number

Use this code only when the 270/271 transaction sets are used by an employer inquiring about eligibility and benefits of their employees.

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Federal Taxpayer's Identification Number

Payor Identification

Use this code only when the information receiver is a payer.

Pharmacy Processor Number

Service Provider Number

Use this code for the identification number assigned by the information source.

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Use this code for the reference number as qualified by the preceding data element (NM108).

INDUSTRY NAME: Information Receiver Identification Number

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - INFORMATION RECEIVER ADDITIONAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information was used from the 270 transaction to identify the Information Receiver. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

TR3 Notes:

TR3 Example:

REF✱EO✱477563928~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
Only one occurrence of each REF01 code value may be used in the 2100B loop.

CODE

DEFINITION

State License Number

The state assigning the license number must be identified in REF03.

Medicare Provider Number

Medicaid Provider Number

Facility ID Number

Personal Identification Number (PIN)

Contract Number

Electronic device pin number

Submitter Identification Number

HPI

Centers for Medicare and Medicaid Services National Provider Identifier

The Centers for Medicare and Medicaid Services National Provider Identifier may be used in this segment prior to being mandated for use.

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

User Identification

Provider Plan Network Identification Number

Facility Network Identification Number

Prior Identifier Number

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Federal Taxpayer's Identification Number

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Information Receiver Additional Identifier

Use this information for the reference number as qualified by the preceding data element (REF01).

Situational

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = "0B". If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver Additional Identifier State

Use this element for the two character state code of the state assigning the identifier supplied in REF02.

See Code source 22: States and Outlying Areas of the U.S.

Not Used

C040

Reference Identifier

O 1

N3 - INFORMATION RECEIVER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N3✱201 PARK AVENUE✱SUITE 300~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Information Receiver Address Line

Use this information for the first line of the address information.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line exists. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver Additional Address Line

N4 - INFORMATION RECEIVER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Information Receiver City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Information Receiver State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

INDUSTRY NAME: Information Receiver Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

AAA - INFORMATION RECEIVER REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request could not be processed at a system or application level when specifically related to the information receiver data contained in the original 270 transaction's information receiver name loop (Loop 2100B) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to indicate problems in processing the transaction specifically related to the information receiver data contained in the original 270 transaction's information receiver name loop (Loop 2100B).

TR3 Example:

AAA✱N✱✱43✱C~

AAA

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

Not Used

559

Agency Qualifier Code

O 1

Required

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.

CODE

DEFINITION

Required application data missing

Use this code only when the information receiver's additional identification is missing.

Authorization/Access Restrictions

Invalid/Missing Provider Identification

Invalid/Missing Provider Name

Invalid/Missing Provider Specialty

Invalid/Missing Provider Phone Number

Invalid/Missing Provider State

Invalid/Missing Referring Provider Identification Number

Provider Ineligible for Inquiries

Provider Not on File

Invalid Participant Identification

Use this code only when the information receiver is not a provider or payer.

Invalid or Missing Provider Address

Payer Name or Identifier Missing

Use this code only when the information receiver is a payer.

Required

889

Follow-up Action Code

O 1

Code identifying follow-up actions allowed

Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

Please Wait 10 Days and Resubmit

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

PRV - INFORMATION RECEIVER PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the 270 request contained a 2100B PRV segment and the information contained in the PRV segment was used to determine the 271 response. If not required by this implementation guide, do not send.

TR3 Notes:

This segment is used to convey additional information about a provider's role in the eligibility/benefit being inquired about and who is also the Information Receiver. For example, if the Information Receiver is also the Referring Provider, this PRV segment would be used to identify the provider's role. This PRV segment applies to all benefits returned for this Information Receiver unless overridden by a PRV segment in the 2100C, 2120C, 2100D or 2120D loops.

TR3 Example:

PRV✱RF✱PXC✱207Q00000X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Attending

Billing

Consulting

Covering

Hospital

Home Health Care

Laboratory

Other Physician

Pharmacist

Pharmacy

Primary Care Physician

Performing

Rural Health Clinic

Referring

Submitting

Skilled Nursing Facility

Supervising

Situational

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when the 270 request contained a 2100B PRV segment and the information contained in PRV02 and PRV03 was used to determine the 271 response. If not required by this implementation guide, do not send.

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Information Receiver Provider Taxonomy Code

Use this number for the reference number as qualified by the preceding data element (PRV02).

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

HL - SUBSCRIBER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required unless the 271 response contains an AAA segment in loop 2000A, 2100A or 2100B. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

TR3 Notes:

Use this segment to identify the hierarchical or entity level of information being conveyed. The HL structure allows for the efficient nesting of related occurrences of information. The developers' intent is to clearly identify the relationship of the patient to the subscriber and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient) can be grouped together under the same provider or the information for multiple providers or information receivers can be grouped together for the same payer or information source. See Section 1.3.2 for limitations on the number of occurrences of patients.
An example of the overall structure of the transaction set when used in batch mode is:

Information Source Loop 2000A
Information Receiver Loop 2000B
Subscriber Loop 2000C
Dependent Loop 2000D
Eligibility or Benefit Information
Subscriber Loop 2000C
Eligibility or Benefit Information
Dependent Loop 2000D
Eligibility or Benefit Information

The above example shows 2 different Subscribers. The first Subscriber is not the patient, only the dependent is the patient. The second Subscriber is a patient and the Dependent is also a patient.

TR3 Example:

HL✱3✱2✱22✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~
HL*3*2*22*1~
NM1*IL*1*SMITH*ROBERT*B***MI*11122333301~
HL*4*3*23*0~
NM1*03*1*SMITH*MARY*LOU~
Eligibility/Benefit Data
HL*5*2*22*0~
NM1*IL*1*BROWN*JOHN*E***MI*22211333301~
Eligibility/Benefit Data
Use the sequentially assigned positive number to identify each specific occurrence of an HL segment within a transaction set. The first HL segment in the transaction must begin with the number 1 and be incremented by 1 for each successive occurrence of the HL segment within that specific transaction set (ST through SE).

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Use this ID number to identify the specific Information Receiver to which this Subscriber is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

All data that follows this HL segment is associated with the Subscriber identified by the level code. This association continues until the next occurrence of an HL segment.

CODE

DEFINITION

Subscriber

Use the subscriber level to identify the insured or subscriber of the health care coverage. This entity may or may not be the actual patient.

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

Because of the hierarchical structure, the code value in the HL04 at the Loop 2000C level should be "1" if a Loop 2000D level (dependent) is associated with this subscriber. If no Loop 2000D level exists for this subscriber, then the code value for HL04 should be "0" (zero).

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

TRN - SUBSCRIBER TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

X12 Set Notes:

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the 270 request contained one or two TRN segments and the subscriber is the patient (See Section 1.4.2.). One TRN segment for each TRN submitted in the 270 must be returned.
OR
Required when the Information Source needs to return a unique trace number for the current transaction.
If not required by this implementation guide, do not send.

TR3 Notes:

An information source may receive up to two TRN segments in each loop 2000C of a 270 transaction and must return each of them in loop 2000C of the 271 transaction unless the person submitted in loop 2000C is determined to be a dependent, then the TRN segments must be returned in loop 2000D. See Section 1.4.2. The returned TRN segments will have a value of "2" in TRN01. See Section 1.4.6 Information Linkage for additional information.
If the subscriber is the patient, an information source may add one TRN segment to loop 2000C with a value of "1" in TRN01 and must identify themselves in TRN03.
This segment must not be used if the subscriber is not the patient. See section 1.4.2. Basic Concepts.
If this transaction passes through a clearinghouse, the clearinghouse will receive from the information source the information receiver's TRN segment and the clearinghouse's TRN segment with a value of "2" in TRN01. Since the ultimate destination of the transaction is the information receiver, if the clearinghouse intends on passing their TRN segment to the information receiver, the clearinghouse must change the value in TRN01 to "1" of their TRN segment. This must be done since the trace number in the clearinghouse's TRN segment is not actually a referenced transaction trace number to the information receiver.
The trace number in the 271 transaction TRN02 must be returned exactly as submitted in the 270 transaction. For example, if the 270 transaction TRN02 was 012345678 it must be returned as 012345678 and not as 12345678.

TR3 Example:

TRN✱2✱98175-012547✱9877281234✱RADIOLOGY~TRN✱2✱109834652831✱9XYZCLEARH✱REALTIME~TRN✱1✱209991094361✱9ABCINSURE~The above example represents how an information source would respond. The first TRN segment was initiated by the information receiver. The second TRN segment was initiated by the clearinghouse. The third TRN segment was initiated by the information source.
TRN✱2✱98175-012547✱9877281234✱RADIOLOGY~TRN✱1✱109834652831✱9XYZCLEARH✱REALTIME~TRN✱1✱209991094361✱9ABCINSURE~The above example represents how a clearinghouse would respond to the same set of TRN segments if the clearinghouse intends to pass their TRN segment on to the information receiver. If the clearinghouse does not intend to pass their TRN segment on to the information receiver, only the first and third TRN segments in the example would be sent.

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

The term "Current Transaction Trace Numbers" refers to trace or reference numbers assigned by the creator of the 271 transaction (the information source).

If a clearinghouse has assigned a TRN segment and intends on returning their TRN segment in the 271 response to the information receiver, they must convert the value in TRN01 to "1" (since it will be returned by the information source as a "2").

Referenced Transaction Trace Numbers

The term "Referenced Transaction Trace Numbers" refers to trace or reference numbers originally sent in the 270 transaction and now returned in the 271.

Required

127

Reference Identification

M 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Trace Number

This element must contain the trace number submitted in TRN02 from the 270 transaction and must be returned exactly as submitted.

Required

509

Originating Company Identifier

O 1

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

SITUATIONAL RULE: If TRN01 is "2", this is the value received in the original 270 transaction.

INDUSTRY NAME: Trace Assigning Entity Identifier

If TRN01 is "1", use this information to identify the organization that assigned this trace number.
If TRN01 is "2", this is the value received in the original 270 transaction.
The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN04 identifies a further subdivision within the organization.

SITUATIONAL RULE: Required when TRN01 = "2" and this element was used in the corresponding 270 TRN segment.ORRequired when TRN01 = "1" and the Information Source needs to further identify a specific component, such as a specific division or group of the entity identified in the previous data element (TRN03).If not required by this implementation guide, do not send.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

NM1*IL - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to identify an entity by name and/or identification number. This NM1 loop is used to identify the insured or subscriber.

TR3 Example:

NM1✱IL✱1✱SMITH✱JOHN✱L✱✱✱MI✱44411555501~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required unless a rejection response is generated and this element was not valued in the request.If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Last Name

Use this name for the subscriber's last name.

OPERATING RULE REQUIREMENTS: The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule EB.1.0 (URL) establishes a methodology for normalizing last names prior to searching for a patient record (Section 2). The rule also establishes what must be returned in the INS segment when the patient was found in the information source's system after normalization, but when the un-normalized last name sent in the request does not match the un-normalized name in the information source's system.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = 1 (Person) and the person has a first name unless a rejection response is generated and this element was not valued in the request. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

Use this name for the subscriber's first name.

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7) unless a rejection response is generated and this element was not valued in the request. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Subscriber Middle Name or Initial

Use this name for the subscriber's middle name or initial.

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

INDUSTRY NAME: Subscriber Name Suffix

Use this for the suffix to an individual's name; e.g., Sr., Jr., or III.

Situational

Identification Code Qualifier

O 1

1/2

Code designating the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required unless a rejection response is generated and this element was not valued in the request.If not required by this implementation guide, do not send.

Use this element to qualify the identification number submitted in NM109. This is the primary number that the information source associates with the subscriber.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Member Identification Number

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required unless a rejection response is generated and this element was not valued in the request.If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Primary Identifier

Use this code for the reference number as qualified by the preceding data element (NM108).

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - SUBSCRIBER ADDITIONAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Source requires additional identifiers necessary to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7);
OR
Required when the 270 request contained a REF segment with a Patient Account Number in Loop 2100C/REF02 with REF01 equal EJ;
OR
Required when the 270 request contained a REF segment and the information provided in that REF segment was used to locate the individual in the information source's system (See Section 1.4.7).
If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

TR3 Notes:

If the 270 request contained a REF segment with a Patient Account Number in REF02 with REF01 equal EJ, then it must be returned in the 271 transaction using this segment if the patient is the Subscriber. The Patient Account Number in the 271 transaction must be returned exactly as submitted in the 270 transaction.
Use this segment to supply an identification number other than or in addition to the Member Identification Number. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100C loop.
Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Numbers are to be provided in the NM1 segment as a Member Identification Number when it is the primary number an information source knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.

TR3 Example:

REF✱EJ✱660415~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
Only one occurrence of each REF01 code value may be used in the 2100C loop.

CODE

DEFINITION

Plan Number

Group or Policy Number

Use this code only if it cannot be determined if the number is a Group Number or a Policy number. Use codes IG or 6P when they can be determined.

Member Identification Number

Use only if Loop 2100C NM108 contains II, and is prior to the mandated use of the HIPAA Unique Patient Identifier.

Case Number

Family Unit Number

Required when the Information Source is a Pharmacy Benefit Manager (PBM) and the individual has a suffix to their member ID number that is required for use in the NCPDP Telecom Standard in the Insurance Segment in field 303-C3 Person Code. If not required by this implementation Guide, do not send.

NOTE: For all other uses, the Family Unit Number (suffix) is considered a part of the Member ID number and is used to uniquely identify the individual and must be returned at the end of the Member ID number in 2100C NM109 or in 2100C REF02 if REF01 is "1W".

Group Number

Class of Contract Code

This code is used in the 835 and may be returned if there is sufficient information contained in the 270 transaction to determine the applicable Class of Contract for claims processing.

Contract Number

Medical Record Identification Number

Patient Account Number

Health Insurance Claim (HIC) Number

See segment note 3.

Identification Card Serial Number

Identity Card Number

Use this code when the Identity Card Number is different than the Member Identification Number. This is particularly prevalent in the Medicaid environment.

Issue Number

Insurance Policy Number

Plan Network Identification Number

Medicaid Recipient Identification Number

See segment note 3.

Prior Identifier Number

This code is to be used when a corrected or new identification number is returned in NM109, the originally submitted identification number is to be returned in REF02. To be used in conjunction with code "001" in INS03 and code "25" in INS04.

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Agency Claim Number

This code is to only to be used when the information source is a Property and Casualty payer. Use this code to identify the Property and Casualty Claim Number associated with the subscriber. This code is not a HIPAA requirement as of this writing.

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Supplemental Identifier

Use this information for the reference number as qualified by the preceding data element (REF01).
If REF01 is "EJ", the Patient Account Number from the 270 transaction must be returned exactly as submitted.

Situational

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = "18", "6P" or "N6" and a name needs to be associated with the corresponding identifier. If not required by this implementation guide, do not send.

INDUSTRY NAME: Group, Insurance Policy or Plan Network Name

Not Used

C040

Reference Identifier

O 1

N3 - SUBSCRIBER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Subscriber is the patient or when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7),
OR
Required if a rejection response is generated and this segment was present in the 270 and is the cause of the rejection.
If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

TR3 Notes:

Do not return address information from the 270 request unless the transaction is rejected and the rejection was caused by the address and this segment was present in the 270. See Section 1.4.7.1 271 item 7 for additional information.
Use this segment to identify address information for a subscriber.

TR3 Example:

N3✱15197 BROADWAY AVENUE✱APT 215~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Subscriber Address Line

Use this information for the first line of the address information.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7) unless a rejection response is generated. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Subscriber Address Line

Use this information for the second line of the address information.

N4 - SUBSCRIBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Do not return address information from the 270 request unless the transaction is rejected and the rejection was caused by the address and this segment was present in the 270. See Section 1.4.7.1 271 item 7 for additional information.
Use this segment to identify address information for a subscriber.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Subscriber City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

INDUSTRY NAME: Subscriber Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Subscriber Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

AAA - SUBSCRIBER REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request could not be processed at a system or application level when specifically related to the data contained in the original 270 transaction's subscriber name loop (Loop 2100C) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to indicate problems in processing the transaction specifically related to the data contained in the original 270 transaction's subscriber name loop (Loop 2100C).

TR3 Example:

AAA✱N✱✱72✱C~

AAA

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

Not Used

559

Agency Qualifier Code

O 1

Required

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.
Use codes "43", "45", "47", "48", or "51" only in response to information that is in or should be in the PRV segment in the Subscriber Name loop (2100C).
See section 1.4.8 Search Options for data content criteria for the subscriber.

CODE

DEFINITION

Required application data missing

Out of Network

Use this code to indicate that the subscriber is not in the Network of the provider identified in the 2100B NM1 segment, or the 2100B/2100CPRV segment if present in the 270 transaction.

Unable to Respond at Current Time

Use this code in a batch environment where an information source returns all requests from the 270 in the 271 and identifies "Unable to Respond at Current Time" for each individual request (subscriber or dependent) within the transaction that they were unable to process for reasons other than data content (such as their system is down or timed out when generating a response).

Invalid/Missing Provider Identification

Invalid/Missing Provider Specialty

Invalid/Missing Provider State

Invalid/Missing Referring Provider Identification Number

Provider is Not Primary Care Physician

Provider Not on File

Service Dates Not Within Provider Plan Enrollment

Inappropriate Date

Invalid/Missing Date(s) of Service

Invalid/Missing Date-of-Birth

Code 58 may not be returned if the information source has located an individual and the Birth Date does not match; use code 71 instead.

Date of Birth Follows Date(s) of Service

Date of Death Precedes Date(s) of Service

Date of Service Not Within Allowable Inquiry Period

Date of Service in Future

Patient Birth Date Does Not Match That for the Patient on the Database

Code 71 must be returned when the transaction was rejected when the information source located an individual based other information submitted, but the Birth Date does not match.

Invalid/Missing Subscriber/Insured ID

Required when the transaction was rejected when the information source cannot find a match for the Subscriber/Insured ID number submitted or if the ID submitted was formatted incorrectly or missing.

Invalid/Missing Subscriber/Insured Name

Required when the transaction was rejected when the information source cannot find a match for the Subscriber Name submitted or if the Subscriber Name was missing.

Invalid/Missing Subscriber/Insured Gender Code

Subscriber/Insured Not Found

Code 75 may not be returned if the information receiver submitted all four pieces of the mandated search option.

Duplicate Subscriber/Insured ID Number

Subscriber/Insured Not in Group/Plan Identified

Required

889

Follow-up Action Code

O 1

Code identifying follow-up actions allowed

Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Use only when AAA03 is "42".

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

Please Wait 10 Days and Resubmit

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

Use only when AAA03 is "42".

PRV - PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the 270 request contained a 2100C PRV segment and the information contained in the PRV segment was used to determine the 271 response.;
OR
Required when needed either to identify a provider's role or to associate a specialty type related to the service identified in the 2110C loops. This PRV segment applies to all benefits in this 2100C loop unless overridden by a PRV segment in the 2120C loop.
If not required by this implementation guide, do not send.

TR3 Notes:

If identifying a specific provider, use this segment to convey specific information about a provider's role in the eligibility/benefit being inquired about or to convey the provider's Taxonomy Code when the provider is not the information receiver. For example, if the information receiver is a hospital and a referring provider must be identified, this is the segment where the referring provider would be identified.
If identifying a type of specialty associated with the services identified in loop 2110C, use code PXC in PRV02 and the appropriate code in PRV03.
If there is a PRV segment in 2100B, this PRV overrides it for this occurrence of the 2100C loop.

TR3 Example:

PRV✱RF✱PXC✱207Q00000X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Attending

Billing

Consulting

Covering

Hospital

Home Health Care

Laboratory

Other Physician

Pharmacist

Pharmacy

Primary Care Physician

Performing

Rural Health Clinic

Referring

Skilled Nursing Facility

Supervising

Situational

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when needed to identify a provider's specialty type. If not required by this implementation guide, do not send.

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when needed to identify a provider's specialty type. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Identifier

Use this number for the reference number as qualified by the preceding data element (PRV02).

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

DMG*D8 - SUBSCRIBER DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

P0102
If either DMG01 or DMG02 is present, then the other is required.
P1011
If either DMG10 or DMG11 is present, then the other is required.
C1105
If DMG11 is present, then DMG05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Subscriber is the patient or when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7), but not required if a rejection response is generated with a 2100C or 2110C AAA segment and this segment was not sent in the request. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

TR3 Notes:

Use this segment to convey the birth date or gender demographic information for the subscriber.

TR3 Example:

DMG✱D8✱19430917✱M~

DMG

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Situational

1250

Date Time Period Format Qualifier

O 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when Subscriber Birth Date is sent in DMG02. If not required by this implementation guide, do not send.

Use this code to indicate the format of the date of birth that follows in DMG02.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

1251

Date Time Period

O 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when the Subscriber is the patient or when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7), but not required if a rejection response is generated with a 2100C or 2110C AAA segment and this segment was not sent in the request. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Subscriber Birth Date

Use this date for the date of birth of the subscriber.

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

INDUSTRY NAME: Subscriber Gender Code

CODE

DEFINITION

Female

Male

Unknown

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

O 10

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

O 1

1/3

Not Used

1271

Industry Code

O 1

1/30

INS*Y - SUBSCRIBER RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit information on insured entities

X12 Syntax:

P1112
If either INS11 or INS12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when acknowledging a change in the identifying elements for the subscriber from those submitted in the 270 or the Birth Sequence Number submitted in INS17 of the 270 was used to locate the Subscriber. If not required by this implementation guide, do not send.

TR3 Example:

INS✱Y✱18✱001✱25~

INS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Yes

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

CODE

DEFINITION

Self

Situational

875

Maintenance Type Code

O 1

Code identifying the specific type of item maintenance

SITUATIONAL RULE: Required along with INS04 when acknowledging a change in the identifying elements for the subscriber from those submitted in the 270. If not required by this implementation guide, do not send.

CODE

DEFINITION

001

Change

Situational

1203

Maintenance Reason Code

O 1

2/3

Code identifying the reason for the maintenance change

SITUATIONAL RULE: Required along with INS03 when acknowledging a change in the identifying elements for the subscriber from those submitted in the 270. If not required by this implementation guide, do not send.

CODE

DEFINITION

Change in Identifying Data Elements

Use this code to indicate that a change has been made to the primary elements that identify a specific person. Such elements are first name, last name, date of birth, identification numbers, and address.

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Situational

1470

Number

O 1

1/9

A generic number

SITUATIONAL RULE: Required when the Birth Sequence Number submitted in the 270 was used to locate the Subscriber. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Birth Sequence Number

Use to indicate the birth order in the event of multiple birth's in association with the birth date supplied in DMG02.

HI - SUBSCRIBER HEALTH CARE DIAGNOSIS CODE

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an HI segment was received in the 270 and if the information source uses the information in the determination of the eligibility or benefit response for the subscriber. All information used from the HI segment of the 270 used in the determination of the eligibility or benefit response for the subscriber must be returned. If information was provided in an HI segment of 270 but was not used in the determination of the eligibility or benefits for the subscriber it must not be returned. The information source must not use information in an HI segment of the 270 transaction in the determination of eligibility or benefits for the subscriber if that information cannot be returned in the 271 response.
OR
Required when needed to identify limitations in the benefits identified in the 2110C loops, such as if benefits are limited for a specific diagnosis code if the information source can support this high level functionality. If the information source cannot support this high level functionality, do not send.

TR3 Notes:

Use the Diagnosis code pointers in 2110C EB14 to identify which diagnosis code or codes in this HI segment relates to the information provided in the EB segment.
Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.

TR3 Example:

HI✱BK:8901✱BF:87200✱BF:5559~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

E codes are Not Used in HI01 except when defined by the claims processor. E codes may be put in any other HI element using BF as the qualifier.
The diagnosis listed in this element is assumed to be the principal diagnosis.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABK

International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

1-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1-4

1251

Date Time Period

O 1

1/35

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

O 1

1/30

Not Used

1-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

2-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

2-4

1251

Date Time Period

O 1

1/35

Not Used

2-5

782

Monetary Amount

O 1

1/18

Not Used

2-6

380

Quantity

O 1

1/15

Not Used

2-7

799

Version Identifier

O 1

1/30

Not Used

2-8

1271

Industry Code

O 1

1/30

Not Used

2-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

3-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

3-4

1251

Date Time Period

O 1

1/35

Not Used

3-5

782

Monetary Amount

O 1

1/18

Not Used

3-6

380

Quantity

O 1

1/15

Not Used

3-7

799

Version Identifier

O 1

1/30

Not Used

3-8

1271

Industry Code

O 1

1/30

Not Used

3-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

4-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

4-4

1251

Date Time Period

O 1

1/35

Not Used

4-5

782

Monetary Amount

O 1

1/18

Not Used

4-6

380

Quantity

O 1

1/15

Not Used

4-7

799

Version Identifier

O 1

1/30

Not Used

4-8

1271

Industry Code

O 1

1/30

Not Used

4-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

5-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

5-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

5-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

5-4

1251

Date Time Period

O 1

1/35

Not Used

5-5

782

Monetary Amount

O 1

1/18

Not Used

5-6

380

Quantity

O 1

1/15

Not Used

5-7

799

Version Identifier

O 1

1/30

Not Used

5-8

1271

Industry Code

O 1

1/30

Not Used

5-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

6-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

6-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

6-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

6-4

1251

Date Time Period

O 1

1/35

Not Used

6-5

782

Monetary Amount

O 1

1/18

Not Used

6-6

380

Quantity

O 1

1/15

Not Used

6-7

799

Version Identifier

O 1

1/30

Not Used

6-8

1271

Industry Code

O 1

1/30

Not Used

6-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

7-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

7-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

7-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

7-4

1251

Date Time Period

O 1

1/35

Not Used

7-5

782

Monetary Amount

O 1

1/18

Not Used

7-6

380

Quantity

O 1

1/15

Not Used

7-7

799

Version Identifier

O 1

1/30

Not Used

7-8

1271

Industry Code

O 1

1/30

Not Used

7-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

8-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

8-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

8-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

8-4

1251

Date Time Period

O 1

1/35

Not Used

8-5

782

Monetary Amount

O 1

1/18

Not Used

8-6

380

Quantity

O 1

1/15

Not Used

8-7

799

Version Identifier

O 1

1/30

Not Used

8-8

1271

Industry Code

O 1

1/30

Not Used

8-9

1073

Yes/No Condition or Response Code

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

DTP - SUBSCRIBER DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required to identify the Plan (DTP01 = 291) or Plan Begin (DTP01 = 346) date when the individual has active coverage unless multiple plans apply to the individual or multiple plan periods apply, which must then be returned in the 2110C DTP (See Section 1.4.7);
OR
Required when needed to identify other relevant dates that apply to the Subscriber.
If not required by this implementation guide, do not send.

TR3 Notes:

The dates represented may be in the past, the current date, or a future date. The dates may also be a single date or a span of dates. Which date(s) to use is determined by the format qualifier in DTP02.
Dates supplied in the 2100C DTP apply to the Subscriber and all 2110C loops unless overridden by an occurrence of a 2110C DTP with the same value in DTP01.

TR3 Example:

DTP✱346✱D8✱19950818~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

096

Discharge

102

Issue

152

Effective Date of Change

291

Plan

307

Eligibility

318

Added

Information Sources are encouraged to return Added date in the case of retroactive eligibility.

340

Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin

341

Consolidated Omnibus Budget Reconciliation Act (COBRA) End

342

Premium Paid to Date Begin

343

Premium Paid to Date End

346

Plan Begin

347

Plan End

356

Eligibility Begin

357

Eligibility End

382

Enrollment

435

Admission

442

Date of Death

458

Certification

472

Service

539

Policy Effective

540

Policy Expiration

636

Date of Last Update

771

Status

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

Use this code to specify the format of the date(s)/time(s) that follow in the next data element.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

Use this date for the date(s) as qualified by the preceding data elements.

MPI - SUBSCRIBER MILITARY PERSONNEL INFORMATION

X12 Name:

Military Personnel Information

X12 Purpose:

To report military service data

X12 Syntax:

P0607
If either MPI06 or MPI07 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this transaction is processed by DOD or CHAMPUS/TRICARE and when necessary to convey the Subscriber's military service data If not required by this implementation guide, do not send.

TR3 Example:

MPI✱C✱AO✱A✱✱L3~Current Active Military - Overseas Air Force Lieutenant Colonel

MPI

✱

1201

Information
Status Code

✱

✱

1595

Gov. Serv.
Affil. Code

✱

✱

✱

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

✱

Required

1201

Information Status Code

M 1

A code to indicate the status of information

CODE

DEFINITION

Partial

Current

Latest

Oldest

Prior

Second Most Current

Third Most Current

Required

584

Employment Status Code

M 1

Code showing the general employment status of an employee/claimant

CODE

DEFINITION

Active Reserve

Active Military - Overseas

Academy Student

Presidential Appointee

Active Military - USA

Contractor

Dishonorably Discharged

Honorably Discharged

Inactive Reserves

Leave of Absence: Military

Plan to Enlist

Recommissioned

Retired Military - Overseas

Retired Without Recall

Retired Military - USA

Required

1595

Government Service Affiliation Code

M 1

Code specifying the government service affiliation

CODE

DEFINITION

Air Force

Air Force Reserves

Army

Army Reserves

Coast Guard

Marine Corps

Marine Corps Reserves

National Guard

Navy

Navy Reserves

Other

Peace Corp

Regular Armed Forces

Reserves

U.S. Public Health Service

Foreign Military

American Red Cross

Department of Defense

United Services Organization

Military Sealift Command

Situational

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SEMANTIC: MPI04 is the actual response to further identify the exact military unit.

SITUATIONAL RULE: Required when needed to further identify the exact military unit. If not required by this implementation guide, do not send.

Situational

1596

Military Service Rank Code

O 1

Code specifying the military service rank

SITUATIONAL RULE: Required when needed to indicate the current or most recent military service rank. If not required by this implementation guide, do not send.

CODE

DEFINITION

Admiral

Airman

Airman First Class

Basic Airman

Brigadier General

Captain

Chief Master Sergeant

Chief Petty Officer

Chief Warrant

Colonel

Commander

Commodore

Corporal

Corporal Specialist 4

Ensign

First Lieutenant

First Sergeant

First Sergeant-Master Sergeant

Fleet Admiral

General

Gunnery Sergeant

Lance Corporal

Lieutenant

Lieutenant Colonel

Lieutenant Commander

Lieutenant General

Lieutenant Junior Grade

Major

Major General

Master Chief Petty Officer

Master Gunnery Sergeant Major

Master Sergeant

Master Sergeant Specialist 8

Petty Officer First Class

Petty Officer Second Class

Petty Officer Third Class

Private

Private First Class

Rear Admiral

Recruit

Seaman

Seaman Apprentice

Seaman Recruit

Second Lieutenant

Senior Chief Petty Officer

Senior Master Sergeant

Sergeant

Sergeant First Class Specialist 7

Sergeant Major Specialist 9

Sergeant Specialist 5

Staff Sergeant

Staff Sergeant Specialist 6

Technical Sergeant

Vice Admiral

Warrant Officer

Situational

1250

Date Time Period Format Qualifier

O 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0607

SITUATIONAL RULE: Required when needed to indicate the beginning date or date span of military service. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

1251

Date Time Period

O 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEMANTIC: MPI07 indicates the date span of military service.

SEGMENT SYNTAX: P0607

SITUATIONAL RULE: Required when needed to indicate the beginning date or date span of military service. If not required by this implementation guide, do not send.

EB - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

X12 Name:

Eligibility or Benefit Information

X12 Purpose:

To supply eligibility or benefit information

X12 Syntax:

P0910
If either EB09 or EB10 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the subscriber is the person whose eligibility or benefits are being described and the transaction is not rejected (see Section 1.4.10) or if the transaction needs to be rejected in this loop. If not required by this implementation guide, do not send.

TR3 Notes:

See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what information must be returned if the subscriber is the person whose eligibility or benefits are being sent.
Either EB03 or EB13 may be used in the same EB segment, not both.
EB03 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110C loop is the same with the exception of the Service Type Code used in EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110C loop are identical.
A limit to the number of repeats of EB loops has not been established. In a batch environment there is no practical reason to limit the number of EB loop repeats. In a real time environment, consideration should be given to how many EB loops are generated given the amount of time it takes to format the response and the amount of time it will take to transmit that response. Since these limitations will vary by information source, it would be completely arbitrary for the developers to set a limit. It is not the intent of the developers to limit the amount of information that is returned in a response, rather to alert information sources to consider the potential delays if the response contains too much information to be formatted and transmitted in real time.
Use this segment to begin the eligibility/benefit information looping structure. The EB segment is used to convey the specific eligibility or benefit information for the entity identified.

TR3 Example:

EB✱1✱FAM✱96✱GP~Active Coverage for subscriber and family, for Professional (Physician) services, and coverage is through a Group Policy
EB✱B✱✱68✱✱✱27✱10~Co-payment for Well Baby Care is $10 per visit
EB✱C✱FAM✱✱✱✱23✱600~Deductible for the family is $600 per calendar year
EB✱L~Primary Care Provider (information about the Primary Care Provider will be located in the 2120 loop)
EB✱A✱✱A6✱✱✱✱✱.50~Co-Insurance is 50 percent for Psychotherapy
EB✱B✱✱98^34^44^81^A0^A3✱✱✱✱10✱✱VS✱1~Co-payment for Professional (Physician) Visit - Office, Chiropractic Office Visits, Home Health Visits, Routine Physical, Professional (Physician) Visit - Outpatient, Professional (Physician) Visit - Home, is $10 for one visit

✱

1390

Eligibility
Benefit Inf

✱

✱

✱

✱

Plan Cvrg
Description

1/50

✱

615

✱

✱

✱

✱

✱

✱

✱

C003

✱

C004

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

Required

1390

Eligibility or Benefit Information Code

M 1

1/2

Code identifying eligibility or benefit information

SEMANTIC: EB01 qualifies EB06 through EB10.

INDUSTRY NAME: Eligibility or Benefit Information

Use this code to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category that is being further described in the following data elements. This data element also qualifies the data in elements EB06 through EB10.
If codes A, B, C, G, J or Y are used, it is required that the patient's portion of responsibility is reflected in either EB07 or EB08. See Section 1.4.9 Patient Responsibility for detailed information and definitions.

OPERATING RULE REQUIREMENTS: The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule EB.1.0 (URL) requires the information source to:

Return the coverage status of all explicit service types, regardless of whether that status is separate and distinct from the plan coverage. This includes coverage of service types for which financial reporting is discretionary. (1.3.2.4)
If coverage is active, return the base and remaining deductible, co-payment, and co-insurance patient responsibility details for the health plan (service type code 30), as well as for explicit service types, if the patient financials are different from the plan coverage (Sections 1.3.2.5 through 1.3.2.8).
Remaining deductibles must be reported only if the 270 inquiry is for the current time period (Section 1.3.2.6.2).

CODE

DEFINITION

Active Coverage

Active - Full Risk Capitation

Active - Services Capitated

Active - Services Capitated to Primary Care Physician

Active - Pending Investigation

Inactive

Inactive - Pending Eligibility Update

Inactive - Pending Investigation

Co-Insurance

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Co-Payment

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Deductible

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Coverage Basis

Benefit Description

Exclusions

Limitations

Out of Pocket (Stop Loss)

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Unlimited

Non-Covered

Cost Containment

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Reserve

Primary Care Provider

Pre-existing Condition

Managed Care Coordinator

Services Restricted to Following Provider

Not Deemed a Medical Necessity

Benefit Disclaimer

Not recommended. See section 1.4.11 Disclaimers Within the Transaction.

Second Surgical Opinion Required

Other or Additional Payor

Prior Year(s) History

Card(s) Reported Lost/Stolen

Code "T" is typically used by Medicaids to indicate to a provider that the person who has presented the ID card is using a stolen ID card.

Contact Following Entity for Eligibility or Benefit Information

Cannot Process

Other Source of Data

Health Care Facility

Spend Down

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Situational

1207

Coverage Level Code

O 1

Code indicating the level of coverage being provided for this insured

SITUATIONAL RULE: Required when needed to identify the types of individuals associated with the eligibility or benefits being identified in the 2110C loop. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Coverage Level Code

This element is used in conjunction with EB01 codes (e.g. Active Family Coverage, Deductible Individual, etc.). This element can be used to identify types of individual's within the Subscriber's family that eligibility or benefits extends to (unless EB01 = E - Exclusions).

OPERATING RULE REQUIREMENTS: The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule EB.1.0 (URL) requires the information source to report both individual and family patient responsibility details for a service type code when amounts or percentages are different for the coverage levels (Section 1.3.2.6).

CODE

DEFINITION

CHD

Children Only

DEP

Dependents Only

ECH

Employee and Children

EMP

Employee Only

ESP

Employee and Spouse

FAM

Family

IND

Individual

SPC

Spouse and Children

SPO

Spouse Only

Situational

1365

Service Type Code

O 99

1/2

Code identifying the classification of service

SEMANTIC: Position of data in the repeating data element conveys no significance.

SITUATIONAL RULE: Required when the subscriber is the patient and has been found in the Information Source's system to identify Active or Inactive Health Benefit Plan Coverage (See Section 1.4.7);ORRequired when one of the Service Type Codes identified in Section 1.4.7 must be returned;ORRequired when responding to a corresponding Service Type code used from the 270 transaction;ORRequired when the eligibility or benefits being identified in the 2110C loop need to be associated with a specific Service Type Code.If not required by this implementation guide or if EB13 is used, do not send.

See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what service type codes must be returned.
EB03 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110C loop is the same with the exception of the Service Type Code used in EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110C loop are identical.
Not used if EB13 is present.

CODE

DEFINITION

Medical Care

Surgical

Consultation

Diagnostic X-Ray

Diagnostic Lab

Radiation Therapy

Anesthesia

Surgical Assistance

Other Medical

Blood Charges

Used Durable Medical Equipment

Durable Medical Equipment Purchase

Ambulatory Service Center Facility

Renal Supplies in the Home

Alternate Method Dialysis

Chronic Renal Disease (CRD) Equipment

Pre-Admission Testing

Durable Medical Equipment Rental

Pneumonia Vaccine

Second Surgical Opinion

Third Surgical Opinion

Social Work

Diagnostic Dental

Periodontics

Restorative

Endodontics

Maxillofacial Prosthetics

Adjunctive Dental Services

Health Benefit Plan Coverage

See Section 1.4.7.1

Plan Waiting Period

Chiropractic

Chiropractic Office Visits

Dental Care

Dental Crowns

Dental Accident

Orthodontics

Prosthodontics

Oral Surgery

Routine (Preventive) Dental

Home Health Care

Home Health Prescriptions

Home Health Visits

Hospice

Respite Care

Hospital

Hospital - Inpatient

Hospital - Room and Board

Hospital - Outpatient

Hospital - Emergency Accident

Hospital - Emergency Medical

Hospital - Ambulatory Surgical

Long Term Care

Major Medical

Medically Related Transportation

Air Transportation

Cabulance

Licensed Ambulance

General Benefits

In-vitro Fertilization

MRI/CAT Scan

Donor Procedures

Acupuncture

Newborn Care

Pathology

Smoking Cessation

Well Baby Care

Maternity

Transplants

Audiology Exam

Inhalation Therapy

Diagnostic Medical

Private Duty Nursing

Prosthetic Device

Dialysis

Otological Exam

Chemotherapy

Allergy Testing

Immunizations

Routine Physical

Family Planning

Infertility

Abortion

AIDS

Emergency Services

Cancer

Pharmacy

Free Standing Prescription Drug

Mail Order Prescription Drug

Brand Name Prescription Drug

Generic Prescription Drug

Podiatry

Podiatry - Office Visits

Podiatry - Nursing Home Visits

Professional (Physician)

Anesthesiologist

Professional (Physician) Visit - Office

Professional (Physician) Visit - Inpatient

Professional (Physician) Visit - Outpatient

Professional (Physician) Visit - Nursing Home

Professional (Physician) Visit - Skilled Nursing Facility

Professional (Physician) Visit - Home

Psychiatric

Psychiatric - Room and Board

Psychotherapy

Psychiatric - Inpatient

Psychiatric - Outpatient

Rehabilitation

Rehabilitation - Room and Board

Rehabilitation - Inpatient

Rehabilitation - Outpatient

Occupational Therapy

Physical Medicine

Speech Therapy

Skilled Nursing Care

Skilled Nursing Care - Room and Board

Substance Abuse

Alcoholism

Drug Addiction

Vision (Optometry)

Frames

Routine Exam

Use for Routine Vision Exam only.

Lenses

Nonmedically Necessary Physical

Experimental Drug Therapy

Burn Care

Brand Name Prescription Drug - Formulary

Brand Name Prescription Drug - Non-Formulary

Independent Medical Evaluation

Partial Hospitalization (Psychiatric)

Day Care (Psychiatric)

Cognitive Therapy

Massage Therapy

Pulmonary Rehabilitation

Cardiac Rehabilitation

Pediatric

Nursery

Skin

Orthopedic

Cardiac

Lymphatic

Gastrointestinal

Endocrine

Neurology

Eye

Invasive Procedures

Gynecological

Obstetrical

Obstetrical/Gynecological

Mail Order Prescription Drug: Brand Name

Mail Order Prescription Drug: Generic

Physician Visit - Office: Sick

Physician Visit - Office: Well

Coronary Care

Private Duty Nursing - Inpatient

Private Duty Nursing - Home

Surgical Benefits - Professional (Physician)

Surgical Benefits - Facility

Mental Health Provider - Inpatient

Mental Health Provider - Outpatient

Mental Health Facility - Inpatient

Mental Health Facility - Outpatient

Substance Abuse Facility - Inpatient

Substance Abuse Facility - Outpatient

Screening X-ray

Screening laboratory

Mammogram, High Risk Patient

Mammogram, Low Risk Patient

Flu Vaccination

Eyewear and Eyewear Accessories

Case Management

Dermatology

Durable Medical Equipment

Diabetic Supplies

Generic Prescription Drug - Formulary

Generic Prescription Drug - Non-Formulary

Allergy

Intensive Care

Mental Health

Neonatal Intensive Care

Oncology

Physical Therapy

Pulmonary

Renal

Residential Psychiatric Treatment

Transitional Care

Transitional Nursery Care

Urgent Care

Situational

1336

Insurance Type Code

O 1

1/3

Code identifying the type of insurance policy within a specific insurance program

SITUATIONAL RULE: Required when the Information Source requires the Subscriber's Insurance Type Code for subsequent EDI transactions (see Section 1.4.7). If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

CODE

DEFINITION

Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan

Medicare Secondary, No-fault Insurance including Auto is Primary

Medicare Secondary Worker's Compensation

Medicare Secondary Public Health Service (PHS)or Other Federal Agency

Medicare Secondary Black Lung

Medicare Secondary Veteran's Administration

Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)

Medicare Secondary, Other Liability Insurance is Primary

Auto Insurance Policy

Commercial

Consolidated Omnibus Budget Reconciliation Act (COBRA)

Medicare Conditionally Primary

Disability

Disability Benefits

Exclusive Provider Organization

Family or Friends

Group Policy

Health Maintenance Organization (HMO)

Health Maintenance Organization (HMO) - Medicare Risk

Special Low Income Medicare Beneficiary

Indemnity

Individual Policy

Long Term Care

Long Term Policy

Life Insurance

Litigation

Medicare Part A

Medicare Part B

Medicaid

Medigap Part A

Medigap Part B

Medicare Primary

Other

When this code is returned by Medicare or a Medicare Part D administrator, this code indicates a type of insurance of Medicare Part D.

Property Insurance - Personal

Personal

Personal Payment (Cash - No Insurance)

Preferred Provider Organization (PPO)

Point of Service (POS)

Qualified Medicare Beneficiary

Property Insurance - Real

Supplemental Policy

Tax Equity Fiscal Responsibility Act (TEFRA)

Workers Compensation

Wrap Up Policy

Situational

1204

Plan Coverage Description

O 1

1/50

A description or number that identifies the plan or coverage

SITUATIONAL RULE: Required when a specific Plan Name exists for the plan which the individual has coverage in conjunction with the 2110C loop with EB01 Status = 1, 2, 3, 4, 5, 6, 7 or 8 and EB03 Service Type Code = 30 (See Section 1.4.7). If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

This element is to be used only to convey the specific product name or special program name for an insurance plan. For example, if a plan has a brand name, such as "Gold 1-2-3", the name may be placed in this element. This element must not be used to give benefit details of a plan.

OPERATING RULE REQUIREMENTS: The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule EB.1.0 (URL) requires the information source to return of the Health Plan Name in EB05 Plan Coverage Description when one exists in their system (Section 1.3.2.1).

Situational

615

Time Period Qualifier

O 1

1/2

Code defining periods

SITUATIONAL RULE: Required when the availability of the eligibility or benefits being identified in the 2110C loop need to be qualified by a time period. If not required by this implementation guide, do not send.

OPERATING RULE REQUIREMENTS: The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule EB.1.0 (URL) requires the information source to return the time period qualifier that describes the base or remaining deductible being reported (Sections 1.3.2.6 through 1.3.2.8).

CODE

DEFINITION

Hour

Day

24 Hours

Years

Service Year

Calendar Year

Year to Date

Contract

Episode

Visit

Outlier

Remaining

Exceeded

Not Exceeded

Lifetime

Lifetime Remaining

Month

Week

Admission

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SITUATIONAL RULE: Required when EB01 = B, C, G, J or Y. Do not use if EB01 = A. May be used at the sender's discretion for other EB01 values. May not be a negative number.

INDUSTRY NAME: Benefit Amount

Use this monetary amount as qualified by EB01.
When EB01 = B, C, G, J or Y, the amount represents the Patient's portion of responsibility. See Section 1.4.9 Patient Responsibility.
Use if eligibility or benefit must be qualified by a monetary amount; e.g., deductible, co-payment.

Situational

954

Percentage as Decimal

O 1

1/10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

SITUATIONAL RULE: Required when EB01 = A. Do not use if EB01 = B, C, G, J or Y. May be used at the sender's discretion for other EB01 values. May not be a negative number.

INDUSTRY NAME: Benefit Percent

Use this percentage rate as qualified by EB01.
When EB01 = A, the amount represents the Patient's portion of responsibility. See Section 1.4.9 Patient Responsibility.
Use if eligibility or benefit must be qualified by a percentage; e.g., co-insurance.

Situational

673

Quantity Qualifier

O 1

Code specifying the type of quantity

SEGMENT SYNTAX: P0910

SITUATIONAL RULE: Required when needed to further qualify the eligibility or benefits being identified in the 2110C loop by quantity. If not required by this implementation guide, do not send.

Use this code to identify the type of units that are being conveyed in the following data element (EB10).

CODE

DEFINITION

Minimum

Quantity Used

Covered - Actual

Covered - Estimated

Number of Co-insurance Days

Deductible Blood Units

Days

Hours

Life-time Reserve - Actual

Life-time Reserve - Estimated

Maximum

Month

Number of Services or Procedures

Quantity Approved

Age, High Value

Use this code when a benefit is based on a maximum age for the patient.

Age, Low Value

Use this code when a benefit is based on a minimum age for the patient.

Visits

Years

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0910

SITUATIONAL RULE: Required when needed to further qualify the eligibility or benefits being identified in the 2110C loop by quantity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Quantity

Use this number for the quantity value as qualified by the preceding data element (EB09).

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: 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.

SITUATIONAL RULE: Required when needed to indicate if authorization or certification is required for the eligibility or benefits being identified in the 2110C loop. If not required by this implementation guide, do not send.

INDUSTRY NAME: Authorization or Certification Indicator

Use code "U" - Unknown, In the event that a payer typically responds Yes or No for some benefits, but the inquired benefit requirements are not accessible or the rules are more complex than can be determined using the data sent in the 270.

CODE

DEFINITION

Unknown

Yes

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SEMANTIC: 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.

SITUATIONAL RULE: Required when needed to indicate if benefits are considered In Plan Network or Out Of Plan Network for the eligibility or benefits being identified in the 2110C loop. If not required by this implementation guide, do not send.

INDUSTRY NAME: In Plan Network Indicator

OPERATING RULE REQUIREMENTS: The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule EB.1.0 (URL) requires the information source to report both in-network and out-of-network patient responsibility details for a service type code when amounts or percentages are different for the network status (Sections 1.3.2.6 through 1.3.2.8).

CODE

DEFINITION

Unknown

Not Applicable

Use code "W" - Not Applicable when benefits are the same regardless of whether they are In Plan-Network or Out of Plan-Network or a Plan-Network does not apply to the benefit.

Yes

Situational

C003

Composite Medical Procedure Identifier

O 1

To identify a medical procedure by its standardized codes and applicable modifiers

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.

SITUATIONAL RULE: Required when a Medical Procedure Code was used from the 270 to determine the response being identified in the 2110C loop;ORRequired when the Information Source supports Medical Procedure Code based 271 transactions and a Medical Procedure Code is available and appropriate for the eligibility or benefits being identified in the 2110C loop.If not required by this implementation guide or if EB03 is used, do not send.

Use this composite data element only if an information source can support this high level of functionality. The EB13 allows for a very specific response.
Not used if EB03 is present.

Required

13-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

Use this code to identify the external code list of the following procedure/service code.

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Current Procedural Terminology (CPT) Codes

CODE SOURCE: 133: Current Procedural Terminology (CPT) Codes

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

CODE SOURCE: 130: Healthcare Common Procedure Coding System

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.

CODE SOURCE: 513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Mutually Defined

Required

13-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Use this ID number for the product/service code as qualified by the preceding data element.

Situational

13-3

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a modifier was used from the 270 to determine the response being identified in the 2110C loop;ORRequired when a modifier clarifies/improves the accuracy of the associated procedure code and the modifier is available.If not required by this implementation guide, do not send.

Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.

Situational

13-4

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.

Situational

13-5

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.

Situational

13-6

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.

Not Used

13-7

352

Description

O 1

1/80

Situational

13-8

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

SITUATIONAL RULE: Required when the Information Source desires to indicate a range of procedure codes. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

EB13-2 indicates the beginning of value of the range of procedure codes and EB13-8 represents the end of the range of procedure codes. All procedure codes in the range will apply.

Situational

C004

Composite Diagnosis Code Pointer

O 1

To identify one or more diagnosis code pointers

X12 COMPOSITE SEMANTIC NOTES:

C004-01 identifies the primary diagnosis code for this service line.
C004-02 identifies the second diagnosis code for this service line.
C004-03 identifies the third diagnosis code for this service line.
C004-04 identifies the fourth diagnosis code for this service line.

SITUATIONAL RULE: Required when a 2100C HI segment is used and the information in this 2110C EB loop is related to a diagnosis code. If 2100C HI segment is not used or if the information in this 2110C EB loop is not related to a diagnosis code, do not send.

See requirements for the use of the 2100C HI segment for additional information.

Required

14-1

1328

Diagnosis Code Pointer

M 1

1/2

A pointer to the diagnosis code in the order of importance to this service

This first pointer designates the primary diagnosis for this EB segment. Remaining diagnosis pointers indicate declining level of importance to the EB segment. Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.

Situational

14-2

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a second diagnosis related to this EB segment. If not required, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.

Situational

14-3

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a third diagnosis related to this EB segment. If not required, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.

Situational

14-4

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a fourth diagnosis related to this EB segment. If not required, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.

HSD - HEALTH CARE SERVICES DELIVERY

X12 Name:

Health Care Services Delivery

X12 Purpose:

To specify the delivery pattern of health care services

X12 Syntax:

P0102
If either HSD01 or HSD02 is present, then the other is required.
C0605
If HSD06 is present, then HSD05 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to identify a specific delivery or usage pattern associated with the benefits identified in either EB03 or EB13. If not required by this implementation guide, do not send.

TR3 Example:

HSD✱VS✱30✱✱✱22~Thirty visits per service year
HSD✱VS✱12✱WK✱3✱34✱1~Twelve visits, three visits per week, for 1 month.

HSD

✱

✱

✱

✱

✱

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

✱

✱

Ship/Del or
Calend Code

✱

Situational

673

Quantity Qualifier

O 1

Code specifying the type of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying type and quantity benefits identified. If not required by this implementation guide, do not send.

Required if HSD02 is used.

CODE

DEFINITION

Days

Units

Hours

Month

Visits

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying type and quantity benefits identified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Quantity

Required if HSD01 is used.

Situational

355

Unit or Basis for Measurement Code

O 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Months

Visit

Week

Years

Situational

1167

Sample Selection Modulus

O 1

1/6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

Situational

615

Time Period Qualifier

O 1

1/2

Code defining periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

CODE

DEFINITION

Hour

Day

Years

Service Year

Calendar Year

Year to Date

Contract

Episode

Visit

Outlier

Remaining

Exceeded

Not Exceeded

Lifetime

Lifetime Remaining

Month

Week

Situational

616

Number of Periods

O 1

1/3

Total number of periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

INDUSTRY NAME: Period Count

Situational

678

Ship/Delivery or Calendar Pattern Code

O 1

1/2

Code which specifies the routine shipments, deliveries, or calendar pattern

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Frequency Code

CODE

DEFINITION

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

1st & 3rd Weeks of the Month

2nd & 4th Weeks of the Month

1st Working Day of Period

Last Working Day of Period

Monday through Friday

Monday through Saturday

Monday through Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Monday through Thursday

Immediately

As Directed

Daily Mon. through Fri.

1/2 Mon. & 1/2 Thurs.

1/2 Tues. & 1/2 Thurs.

1/2 Wed. & 1/2 Fri.

Once Anytime Mon. through Fri.

Tuesday through Friday

Monday, Tuesday and Thursday

Monday, Tuesday and Friday

Wednesday and Thursday

Monday, Wednesday and Thursday

Tuesday, Thursday and Friday

1/2 Tue. & 1/2 Fri.

1/2 Mon. & 1/2 Wed.

1/3 Mon., 1/3 Wed., 1/3 Fri.

Whenever Necessary

1/2 By Wed., Bal. By Fri.

None (Also Used to Cancel or Override a Previous Pattern)

Situational

679

Ship/Delivery Pattern Time Code

O 1

Code which specifies the time for routine shipments or deliveries

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Pattern Time Code

CODE

DEFINITION

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

As Directed

Any Shift

None (Also Used to Cancel or Override a Previous Pattern)

REF - SUBSCRIBER ADDITIONAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Source requires one or more of these additional identifiers for subsequent EDI transactions (see Section 1.4.7);
OR
Required when an additional identifier is associated with the eligibility or benefits being identified in the 2110C loop. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment for reference identifiers related only to the 2110C loop that it is contained in (e.g. Other or Additional Payer's identifiers).
Use this segment to identify other or additional reference numbers for the entity identified. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2110C loop.

TR3 Example:

REF✱G1✱653745725~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
Use "1W", "49", "F6", and "NQ" only in a 2110C loop with EB01 = "R".
Only one occurrence of each REF01 code value may be used in the 2110C loop.

CODE

DEFINITION

Plan Number

Group or Policy Number

Use this code only if it cannot be determined if the number is a Group Number or a Policy number. Use codes "IG" or "6P" when they can be determined.

Member Identification Number

Family Unit Number

Group Number

Referral Number

ALS

Alternative List ID

Allows the source to identify the list identifier of a list of drugs and its alternative drugs with the associated formulary status for the patient.

CLI

Coverage List ID

Allows the source to identify the list identifier of a list of drugs that have coverage limitations for the associated patient.

Health Insurance Claim (HIC) Number

Drug Formulary Number

Prior Authorization Number

Insurance Policy Number

Medical Assistance Category

Plan Network Identification Number

Medicaid Recipient Identification Number

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Eligibility or Benefit Identifier

Use this information for the reference number as qualified by the preceding data element (REF01).

Situational

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = "18", "6P" or "N6" and a name needs to be associated with the corresponding identifier. If not required by this implementation guide, do not send.

INDUSTRY NAME: Group, Insurance Policy or Plan Network Name

Not Used

C040

Reference Identifier

O 1

DTP - SUBSCRIBER ELIGIBILITY/BENEFIT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the individual has active coverage with multiple plans or multiple plan periods apply (See 2100C DTP segment);
OR
Required when needed to convey dates associated with the eligibility or benefits being identified in the 2110C loop.
If not required by this implementation guide, do not send.

TR3 Notes:

When using the DTP segment in the 2110C loop this date applies only to the 2110C Eligibility or Benefit Information (EB) loop in which it is located.

If a DTP segment with the same DTP01 value is present in the 2100C loop, the date is overridden for only this 2110C Eligibility or Benefit Information (EB) loop.

TR3 Example:

DTP✱472✱D8✱19960624~

DTP

✱

✱

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

096

Discharge

193

Period Start

194

Period End

198

Completion

290

Coordination of Benefits

291

Plan

Use code 291 only if multiple plans apply to the individual or multiple plan periods apply. Dates supplied in this DTP segment only apply to the 2110C loop in which it occurs.

292

Benefit

295

Primary Care Provider

304

Latest Visit or Consultation

307

Eligibility

318

Added

346

Plan Begin

Use code 346 only if multiple plans apply to the individual or multiple plan periods apply. Dates supplied in this DTP segment only apply to the 2110C loop in which it occurs.

348

Benefit Begin

349

Benefit End

356

Eligibility Begin

357

Eligibility End

435

Admission

472

Service

636

Date of Last Update

771

Status

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

Use this code to specify the format of the date(s)/time(s) that follow in the next data element.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Eligibility or Benefit Date Time Period

Use this date for the date(s) as qualified by the preceding data elements.

AAA - SUBSCRIBER REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request could not be processed at a system or application level when specifically related to specific eligibility/benefit inquiry data contained in the original 270 transaction's subscriber eligibility/benefit inquiry information loop (Loop 2110C) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to indicate problems in processing the transaction specifically related to specific eligibility/benefit inquiry data contained in the original 270 transaction's subscriber eligibility/benefit inquiry information loop (Loop 2110C).

TR3 Example:

AAA✱N✱✱70✱C~

AAA

✱

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

Not Used

559

Agency Qualifier Code

O 1

Required

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.

CODE

DEFINITION

Required application data missing

Input Errors

Use this code only when data is present in this transaction and no other Reject Reason Code is valid for describing the error. Detail of the error must be supplied in the MSG segment of the 2110C loop containing this Reject Reason Code.

Service Dates Not Within Provider Plan Enrollment

Inquired Benefit Inconsistent with Provider Type

Inappropriate Product/Service ID Qualifier

Inappropriate Product/Service ID

Inappropriate Date

Invalid/Missing Date(s) of Service

Date of Birth Follows Date(s) of Service

Date of Death Precedes Date(s) of Service

Date of Service Not Within Allowable Inquiry Period

Date of Service in Future

Inconsistent with Patient's Age

Inconsistent with Patient's Gender

Experimental Service or Procedure

Authorization Number Not Found

Use this code only when the Referral Number or Prior Authorization Number in 2110C REF02 is not found.

Requires Primary Care Physician Authorization

Invalid/Missing Diagnosis Code(s)

Invalid/Missing Procedure Code(s)

Use this code for errors with Procedure Codes in EQ02-2 or Procedure Code Modifiers in EQ02-3 through EQ02-6.

Additional Patient Condition Information Required

Use this code only if the Information Source supports responding to a detailed eligibility request and the information can be processed from a 270 transaction received by the Information Source but was not received and is needed to respond appropriately.

Certification Information Does Not Match Patient

Use this code only when the Referral Number or Prior Authorization Number in 2110C REF02 is found but is not associated with the subscriber.

Requires Medical Review

Invalid Authorization Number Format

Use this code only when the Referral Number or Prior Authorization Number in 2110C REF02 is not formatted properly.

Missing Authorization Number

Use this code only when the Referral Number or Prior Authorization Number has been issued and is missing in 2110C REF02 but is needed to respond appropriately.

Required

889

Follow-up Action Code

O 1

Code identifying follow-up actions allowed

Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Please Wait 30 Days and Resubmit

Please Wait 10 Days and Resubmit

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

MSG - MESSAGE TEXT

X12 Name:

Message Text

X12 Purpose:

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

X12 Syntax:

C0302
If MSG03 is present, then MSG02 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the eligibility or benefit information cannot be codified in existing data elements (including combinations of multiple data elements and segments);
AND
Required when this information is pertinent to the eligibility or benefit response.
If not required by this implementation guide, do not send.

TR3 Notes:

Free form text or description fields are not recommended because they require human interpretation.
Under no circumstances can an information source use the MSG segment to relay information that can be sent using codified information in existing data elements (including combinations of multiple data elements and segments). Information that has been provided in codified form in other segments or elements elsewhere in the 271 for the individual must not be repeated in the MSG segment. If the information cannot be codified, then cautionary use of the MSG segment is allowed as a short term solution. It is highly recommended that the entity needing to use the MSG segment approach X12N with data maintenance to solve the long term business need, so the use of the MSG segment can be avoided for that issue.
Benefit Disclaimers are strongly discouraged. See section 1.4.11 Disclaimers Within the Transaction. Under no circumstances are more than one MSG segment to be used for a Benefit Disclaimer per individual response.

TR3 Example:

MSG✱Free form text is discouraged~

MSG

✱

933

Loop 2115C - SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION

✱

✱

Required

933

Free-form Message Text

M 1

1/264

Free-form message text

INDUSTRY NAME: Free Form Message Text

Not Used

934

Printer Carriage Control Code

O 1

Not Used

1470

Number

O 1

1/9

III - SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION

X12 Name:

Information

X12 Purpose:

To report information

X12 Syntax:

P0102
If either III01 or III02 is present, then the other is required.
L030405
If III03 is present, then at least one of III04 or III05 are required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when III segments in Loop 2110C of the 270 Inquiry were used in the determination of the eligibility or benefit response;
OR
Required when needed to identify limitations in the benefits explained in the corresponding Loop 2110C (such as if benefits are limited to a type of facility).
If not required by this implementation guide, do not send.

TR3 Notes:

This segment has two purposes. Information that was received in III segments in Loop 2110C of the 270 Inquiry and was used in the determination of the eligibility or benefit response must be returned. If information was provided in III segments of Loop 2110C but was not used in the determination of the eligibility or benefits it must not be returned. This segment can also be used to identify limitations in the benefits explained in the corresponding Loop 2110C, such as if benefits are limited to a type of facility.
Use this segment to identify Nature of Injury Codes and/or Facility Type as they relate to the information provided in the EB segment.
Use the III segment only if an information source can support this high level functionality.
Use this segment only one time for the Facility Type Code.

TR3 Example:

III✱ZZ✱21~III✱✱✱44✱Broken bones and third degree burns~

III

✱

✱

✱

✱

✱

✱

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

✱

✱

✱

Situational

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying a Nature of Injury Code or a Facility Type Code. If not required by this implementation guide, do not send.

Use this code to specify if the code that is following in the III02 is a Nature of Injury Code or a Facility Type Code.

CODE

DEFINITION

National Council on Compensation Insurance (NCCI) Nature of Injury Code

CODE SOURCE: 284: Nature of Injury Code

Nature of Injury Code

Other code source as specified by the jurisdiction.

CODE SOURCE: 407: Occupational Injury and Illness Classification Manual

Mutually Defined

Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of Service Codes for Professional Claims.

Situational

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying a Nature of Injury Code or a Facility Type Code. If not required by this implementation guide, do not send.

If III01 is GR, use this element for NCCI Nature of Injury code from code source 284.
If III01 is NI, use this element for Nature of Injury code from code source 407.
If III01 is ZZ, use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below, however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here.

01 Pharmacy
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-based Facility
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service

Situational

1136

Code Category

O 1

Specifies the situation or category to which the code applies

SEMANTIC: III03 is used to categorize III04.

SEGMENT SYNTAX: L030405

SITUATIONAL RULE: Required when III01 and III02 are not present or if additional information is needed (see III04). If not required by this implementation guide or if III01 is ZZ, do not send.

CODE

DEFINITION

Nature of Injury

Situational

933

Free-form Message Text

O 1

1/264

Free-form message text

SEGMENT SYNTAX: L030405

SITUATIONAL RULE: Required when III03 = "44". If not required by this implementation guide, do not send.

INDUSTRY NAME: Injured Body Part Name

Use this element to describe the injured body part or parts.

Not Used

380

Quantity

O 1

1/15

Not Used

C001

Composite Unit of Measure

O 1

Not Used

752

Surface/Layer/Position Code

O 1

Not Used

752

Surface/Layer/Position Code

O 1

Not Used

752

Surface/Layer/Position Code

O 1

LS - LOOP HEADER

X12 Name:

Loop Header

X12 Purpose:

To indicate that the next segment begins a loop

X12 Comments:

See Figures Appendix for an explanation of the use of the LS and LE segments.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when Loop 2120C is used. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to identify the beginning of the Subscriber Benefit Related Entity Name loop. Because both the subscriber's name loop and this loop begin with NM1 segments, the LS and LE segments are used to differentiate these two loops.

TR3 Example:

LS✱2120~

✱

Required

447

Loop Identifier Code

M 1

1/4

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

This data element must have the value of "2120".

NM1 - SUBSCRIBER BENEFIT RELATED ENTITY NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop 2120C - SUBSCRIBER BENEFIT RELATED ENTITY NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when provider was identified in 2100C PRV02 and PRV03 by Identification Number (not Taxonomy Code) in the 270 Inquiry and was used in the determination of the eligibility or benefit response;
OR
Required when needed to identify an entity associated with the eligibility or benefits being identified in the 2110C loop such as a provider (e.g. primary care provider), an individual, an organization, another payer, or another information source;
If not required by this implementation guide, do not send.

TR3 Example:

NM1✱P3✱1✱JONES✱MARCUS✱✱✱MD✱SV✱111223333~

NM1

✱

✱

Loop 2120C - SUBSCRIBER BENEFIT RELATED ENTITY NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Contracted Service Provider

Preferred Provider Organization (PPO)

Use if identifying a Preferred Provider Organization (PPO) by name or identification number. May also be used if identifying the Network that benefits are restricted to when 2110C EB12 = "Y" (In-Network).

Provider

Third-Party Administrator

Employer

Other Physician

Facility

Gateway Provider

Group

Independent Physicians Association (IPA)

Insured or Subscriber

Use if identifying an insured or subscriber to a plan other than the information source (such as in a co-ordination of benefits situation).

Legal Representative

Origin Carrier

Use if identifying an organization that added information relating to other insurance.

Primary Care Provider

Prior Insurance Carrier

Plan Sponsor

Payer

PRP

Primary Payer

SEP

Secondary Payer

TTP

Tertiary Payer

VER

Party Performing Verification

Use this code when identifying the true Information Source and no other code is appropriate. See Section 1.4.7.1 271 item 11 for additional information.

Vendor

Organization Completing Configuration Change

Use if identifying an organization that changed information relating to other insurance.

Utilization Management Organization

Managed Care Organization

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

Use this code to indicate whether the entity is an individual person or an organization.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when needed to identify by name an entity associated with the eligibility or benefits being identified in the 2110C loop such as a provider (e.g. Primary Care Provider), an individual, an organization, another payer, or another information sourceORRequired when NM109 is not used.If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Last or Organization Name

Use this name for the organization name if the entity type qualifier is a non-person entity. Otherwise, this will be the individual's last name.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 is "1" and NM103 is used. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 is "1" and the Last Name in NM103 and First Name in NM104 are not sufficient to identify the individual. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Benefit Related Entity Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 is "1" and the Last Name in NM103 and First Name in NM104 and/or Middle Name in 2100A NM105 are not sufficient to identify the individual. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Benefit Related Entity Name Suffix

Use for name suffix only (e.g. Sr, Jr, II, III, etc.).

Situational

Identification Code Qualifier

O 1

1/2

Code designating the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when needed to identify by Identification Code an entity associated with the eligibility or benefits being identified in the 2110C loop such as a provider (e.g. Primary Care Provider), an individual, an organization, another payer, or another information source.ORRequired when NM103 is not used.If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

Use code value "XX" if the entity is a provider and the National Provider ID is mandated for use.
Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
If the entity being identified is an individual, the "HIPAA Individual Identifier" must be used once this identifier has been adopted.
Otherwise use appropriate code value for the entity.

CODE

DEFINITION

Employer's Identification Number

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Electronic Transmitter Identification Number (ETIN)

Facility Identification

Federal Taxpayer's Identification Number

Standard Unique Health Identifier for each Individual in the United States

Member Identification Number

Use this code to identify the entity's Member Identification Number associated with a payer other than the information source in Loop 2100A. This code may only be used prior to the mandated use of code "II".

National Association of Insurance Commissioners (NAIC) Identification

Payor Identification

Pharmacy Processor Number

Service Provider Number

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Benefit Related Entity Identifier

Use this code for the reference number as qualified by the preceding data element (NM108).

Situational

706

Entity Relationship Code

O 1

Code describing entity relationship

COMMENT: NM110 and NM111 further define the type of entity in NM101.

SEGMENT SYNTAX: C1110

SITUATIONAL RULE: Required when needed to indicate the Benefit Related Entity's relationship to the patient when EB01 = "R", the coverage is based on the Benefit Related Entity and the relationship is known. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Benefit Related Entity Relationship Code

CODE

DEFINITION

Parent

Child

Domestic Partner

Spouse

Employee

Other

Unknown

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - SUBSCRIBER BENEFIT RELATED ENTITY ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to further identify the entity or individual in loop 2120C NM1 and the information is available. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to identify address information for an entity.

TR3 Example:

N3✱201 PARK AVENUE✱SUITE 300~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Benefit Related Entity Address Line

Use this information for the first line of the address information.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line exists and is available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Address Line

Use this information for the second line of the address information.

N4 - SUBSCRIBER BENEFIT RELATED ENTITY CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop 2120C - SUBSCRIBER BENEFIT RELATED ENTITY NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to further identify the entity or individual in loop 2120C NM1 and the information is available. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to identify address information for an entity.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Benefit Related Entity City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

INDUSTRY NAME: Benefit Related Entity Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Situational

309

Location Qualifier

O 1

1/2

Code identifying type of location

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed by CHAMPUS/TRICARE or CHAMPVA to communicate the DOD Health Service Region. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Location Qualifier

Use this element only to communicate the Department of Defense Health Service Region.

CODE SOURCE 206: Government Bill of Lading Office Code

CODE

DEFINITION

Region

Use this code only to communicate the Department of Defense Health Service Region in N406.

Situational

310

Location Identifier

O 1

1/30

Code which identifies a specific location

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed by CHAMPUS/TRICARE or CHAMPVA to communicate the DOD Health Service Region. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity DOD Health Service Region

Use this element only to communicate the Department of Defense Health Service Region.
CODE SOURCE DOD1: Military Health Systems Functional Area Manual - Data.

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Benefit Related Entity Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

PER*IC - SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop 2120C - SUBSCRIBER BENEFIT RELATED ENTITY NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when Contact Information exists and is available. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment when needed to identify a contact name and/or communications number for the entity identified. This segment allows for three contact numbers to be listed. This segment is used when the information source wishes to provide a contact for the entity identified in loop 2120C NM1.

If telephone extension is sent, it should always be in the occurrence of the communications number following the actual phone number. See the example for an illustration.
If this segment is used, at a minimum either PER02 must be used or PER03 and PER04 must be used. It is recommended that at least PER02, PER03 and PER04 are sent if this segment is used.
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.

TR3 Example:

PER✱IC✱BILLING DEPT✱TE✱2128763654✱EX✱2104✱FX✱2128769304~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

Loop 2120C - SUBSCRIBER BENEFIT RELATED ENTITY NAME

1/20

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

Use this code to specify the type of person or group to which the contact number applies.

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the name of the individual to contact is not already defined or is different than the name within 2120C NM1 segment and the name is available;ORRequired when PER03 and PER04 are not present.If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Benefit Related Entity Contact Name

Use this name for the individual's name or group's name to use when contacting the individual or organization.

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when PER02 is not present or when a communication number, e-mail or Web address is to be sent in addition to the contact name. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

Use this code to specify what type of communication number is following.

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Work Phone Number

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Benefit Related Entity Communication Number

The format for US domestic phone numbers is:
AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number
Use this for the communication number or URL as qualified by the preceding data element.

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a second communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

Use this code to specify what type of communication number is following.

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Work Phone Number

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a second communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Communication Number

The format for US domestic phone numbers is:
AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number
Use this for the communication number or URL as qualified by the preceding data element.

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a third communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

Use this code to specify what type of communication number is following.

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Work Phone Number

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a third communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Communication Number

The format for US domestic phone numbers is:
AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number
Use this for the communication number or URL as qualified by the preceding data element.

Not Used

443

Contact Inquiry Reference

O 1

1/20

PRV - SUBSCRIBER BENEFIT RELATED PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed either to identify a provider's role or associate a specialty type related to the service identified in the 2110C loop. If not required by this implementation guide, do not send.

TR3 Notes:

If identifying a type of specialty associated with the services identified in loop 2110C, use code PXC in PRV02 and the appropriate code in PRV03.
If there is a PRV segment in 2100B or 2100C, this PRV overrides it for this occurrence of the 2110C loop.

TR3 Example:

PRV✱PE✱PXC✱207Q00000X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Attending

Billing

Consulting

Covering

Hospital

Home Health Care

Laboratory

Other Physician

Pharmacist

Pharmacy

Primary Care Physician

Performing

Rural Health Clinic

Referring

Submitting

Skilled Nursing Facility

Supervising

Situational

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when needed to identify a provider's specialty type related to the service identified in the 2110C loop. If not required by this implementation guide, do not send.

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when needed to identify a provider's specialty type related to the service identified in the 2110C loop. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Provider Taxonomy Code

Use this reference number as qualified by the preceding data element (PRV02).

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

LE - LOOP TRAILER

X12 Name:

Loop Trailer

X12 Purpose:

To indicate that the loop immediately preceding this segment is complete

X12 Comments:

See Figures Appendix for an explanation of the use of the LE and LS segments.

Loop:

Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when Loop 2120C is used. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to identify the end of the Subscriber Benefit Related Entity Name loop. Because both the subscriber's name loop and this loop begin with NM1 segments, the LS and LE segments are used to differentiate these two loops.

TR3 Example:

LE✱2120~

✱

Required

447

Loop Identifier Code

M 1

1/4

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

This data element must have the value of "2120".

HL - DEPENDENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required if the patient is a dependent who does not have a unique Member Identification Number (See Section 1.4.2) unless the 271 response contains an AAA segment in loop 2000A, 2100A, 2100B, 2100C or 2110C. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

TR3 Notes:

See Section 1.4.2 Basic Concepts for more information about dependents and patients.
Use this segment to identify the hierarchical or entity level of information being conveyed. The HL structure allows for the efficient nesting of related occurrences of information. The developers' intent is to clearly identify the relationship of the patient to the subscriber and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient) can be grouped together under the same provider or the information for multiple providers or information receivers can be grouped together for the same payer or information source. See Section 1.3.2 for limitations on the number of occurrences of patients.
An example of the overall structure of the transaction set when used in batch mode is:

Information Source Loop 2000A
Information Receiver Loop 2000B
Subscriber Loop 2000C
Dependent Loop 2000D
Eligibility or Benefit Information
Subscriber Loop 2000C
Eligibility or Benefit Information
Dependent Loop 2000D
Eligibility or Benefit Information

The above example shows 2 different Subscribers. The first Subscriber is not the patient, only the dependent is the patient. The second Subscriber is a patient and the Dependent is also a patient.

TR3 Example:

HL✱4✱3✱23✱0~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

Use the sequentially assigned positive number to identify each specific occurrence of an HL segment within a transaction set. The first HL segment in the transaction must begin with the number 1 and be incremented by 1 for each successive occurrence of the HL segment within that specific transaction set (ST through SE).
An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~
HL*3*2*22*1~
NM1*IL*1*SMITH*ROBERT*B***MI*11122333301~
HL*4*3*23*0~
NM1*03*1*SMITH*MARY*LOU~
Eligibility/Benefit Data
HL*5*2*22*0~
NM1*IL*1*BROWN*JOHN*E***MI*22211333301~
Eligibility/Benefit Data

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Use this ID number to identify the specific Subscriber to which this Dependent is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code defining the characteristic of a level in a hierarchical structure

All data that follows this HL segment is associated with the Dependent identified by the level code. This association continues until the next occurrence of an HL segment.

CODE

DEFINITION

Dependent

Use the dependent level to identify an individual(s) who may be a dependent of the subscriber/insured. This entity may or may not be the actual patient.

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

Because of the hierarchical structure, and because no subordinate HL levels exist, the code value in the HL04 at the Loop 2000D level must be "0" (zero).

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

TRN - DEPENDENT TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

X12 Set Notes:

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the 270 request contained one or two TRN segments and the dependent is the patient (See Section 1.4.2.). One TRN segment for each TRN submitted in the 270 must be returned.;
OR
Required when the Information Source needs to return a unique trace number for the current transaction.
If not required by this implementation guide, do not send.

TR3 Notes:

An information source may receive up to two TRN segments in each loop 2000D of a 270 transaction and must return each of them in loop 2000D of the 271 transaction unless the person submitted in loop 2000D is determined to be a subscriber, then the TRN segments must be returned in loop 2000C (See Section 1.4.2). The returned TRN segments will have a value of "2" in TRN01. See Section 1.4.6 Information Linkage for additional information.
An information source may add one TRN segment to loop 2000D with a value of "1" in TRN01 and must identify themselves in TRN03.
If this transaction passes through a clearinghouse, the clearinghouse will receive from the information source the information receiver's TRN segment and the clearinghouse's TRN segment with a value of "2" in TRN01. Since the ultimate destination of the transaction is the information receiver, if the clearinghouse intends on passing their TRN segment to the information receiver, the clearinghouse must change the value in TRN01 to "1" of their TRN segment. This must be done since the trace number in the clearinghouse's TRN segment is not actually a referenced transaction trace number to the information receiver.
The trace number in the 271 transaction TRN02 must be returned exactly as submitted in the 270 transaction. For example, if the 270 transaction TRN02 was 012345678 it must be returned as 012345678 and not as 12345678.

TR3 Example:

TRN✱2✱98175-012547✱9877281234✱RADIOLOGY~TRN✱2✱109834652831✱9XYZCLEARH✱REALTIME~TRN✱1✱209991094361✱9ABCINSURE~The above example represents how an information source would respond. The first TRN segment was initiated by the information receiver. The second TRN segment was initiated by the clearinghouse. The third TRN segment was initiated by the information source.
TRN✱2✱98175-012547✱9877281234✱RADIOLOGY~TRN✱1✱109834652831✱9XYZCLEARH✱REALTIME~TRN✱1✱209991094361✱9ABCINSURE~The above example represents how a clearinghouse would respond to the same set of TRN segments if the clearinghouse intends to pass their TRN segment on to the information receiver. If the clearinghouse does not intend to pass their TRN segment on to the information receiver, only the first and third TRN segments in the example would be sent.

TRN

✱

✱

✱

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Referenced Transaction Trace Numbers

The term "Referenced Transaction Trace Numbers" refers to trace or reference numbers originally sent in the 270 transaction and now returned in the 271.

Required

127

Reference Identification

M 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Trace Number

This element must contain the trace number submitted in TRN02 from the 270 transaction and must be returned exactly as submitted.

Required

509

Originating Company Identifier

O 1

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

SITUATIONAL RULE: If TRN01 is <169>2<170>, this is the value received in the original 270 transaction.

INDUSTRY NAME: Trace Assigning Entity Identifier

If TRN01 is "1", use this information to identify the organization that assigned this trace number.
If TRN01 is "2", this is the value received in the original 270 transaction.
The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN04 identifies a further subdivision within the organization.

SITUATIONAL RULE: Required when TRN01 = "2" and this element was used in the corresponding 270 TRN segment.;ORRequired when TRN01 = "1" and the Information Source needs to further identify a specific component, such as a specific division or group of the entity identified in the previous data element (TRN03).If not required by this implementation guide, do not send.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

If TRN01 is "1", use this information if necessary to further identify a specific component, such as a specific division or group of the entity identified in the previous data element (TRN03).
If TRN01 is "2", this is the value received in the original 270 transaction.

NM1*03 - DEPENDENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this segment to identify an entity by name. This NM1 loop is used to identify the dependent of an insured or subscriber.

TR3 Example:

NM1✱03✱1✱SMITH✱JOHN✱L✱✱JR~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Dependent

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required unless a rejection response is generated and this element was not valued in the request.If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Last Name

Use this name for the dependent's last name.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required unless a rejection response is generated and this element was not valued in the request.If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent First Name

Use this name for the dependent's first name.

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the Information Source requires this information to identify the Dependent for subsequent EDI transactions (see Section 1.4.7) unless a rejection response is generated and this element was not valued in the request. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Dependent Middle Name or Initial

Use this name for the dependent's middle name or initial.

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

INDUSTRY NAME: Dependent Name Suffix

Use this for the suffix to an individual's name; e.g., Sr., Jr., or III.

Not Used

Identification Code Qualifier

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

REF - DEPENDENT ADDITIONAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Source requires additional identifiers necessary to identify the Dependent for subsequent EDI transactions (see Section 1.4.7);
OR
Required when the 270 request contained a REF segment with a Patient Account Number in Loop 2100D/REF02 with REF01 equal EJ;
OR
Required when the 270 request contained a REF segment and the information provided in that REF segment was used to locate the individual in the information source's system (See Section 1.4.7).
If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

TR3 Notes:

If the 270 request contained a REF segment with a Patient Account Number in Loop 2100D/REF02 with REF01 equal EJ, then it must be returned in the 271 transaction using this segment if the patient is the Dependent. The Patient Account Number in the 271 transaction must be returned exactly as submitted in the 270 transaction.
Use this segment to supply an identification number other than or in addition to the Member Identification Number. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100D loop.
Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Numbers are to be provided in the NM1 segment as a Member Identification Number when it is the primary number an information source knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.

TR3 Example:

REF✱EJ✱660415~
REF✱49✱03~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
Only one occurrence of each REF01 code value may be used in the 2100D loop.

CODE

DEFINITION

Plan Number

Group or Policy Number

Use this code only if it cannot be determined if the number is a Group Number or a Policy number. Use codes "IG" or "6P" when they can be determined.

Member Identification Number

Required only for Property and Casualty use when the Property and Casualty Patient Identifier is a Member ID and needed for 837 claims in 2010CA REF. This code must not be used for any other purposes.

Family Unit Number

Group Number

Class of Contract Code

This code is used in the 835 and may be returned if there is sufficient information contained in the 270 transaction to determine the applicable Class of Contract for claims processing.

Contract Number

Medical Record Identification Number

Patient Account Number

Health Insurance Claim (HIC) Number

See segment note 3.

Identification Card Serial Number

Identity Card Number

Use this code when the Identity Card Number is different than the Member Identification Number. This is particularly prevalent in the Medicaid environment.

Issue Number

Insurance Policy Number

MRC

Eligibility Category

CODE SOURCE: 844: Eligibility Category

Plan Network Identification Number

Medicaid Recipient Identification Number

See segment note 3.

Prior Identifier Number

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Agency Claim Number

This code is to only to be used when the information source is a Property and Casualty payer. Use this code to identify the Property and Casualty Claim Number associated with the dependent. This code is not a HIPAA requirement as of this writing.

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Dependent Supplemental Identifier

Use this information for the reference number as qualified by the preceding data element (REF01).
If REF01 is "EJ", the Patient Account Number from the 270 transaction must be returned exactly as submitted.

Situational

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = "18", "6P" or "N6" and a name needs to be associated with the corresponding identifier. If not required by this implementation guide, do not send.

INDUSTRY NAME: Group, Insurance Policy or Plan Network Name

Not Used

C040

Reference Identifier

O 1

N3 - DEPENDENT ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Source requires this information to identify the Dependent for subsequent EDI transactions (see Section 1.4.7),
OR
Required if a rejection response is generated and this segment was present in the 270 and is the cause of the rejection.
If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

TR3 Notes:

Do not return address information from the 270 request unless the transaction is rejected and the rejection was caused by the address and this segment was present in the 270. See Section 1.4.7.1 271 item 7 for additional information.
Use this segment to identify address information for a dependent.

TR3 Example:

N3✱15197 BROADWAY AVENUE✱APT 215~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Dependent Address Line

Use this information for the first line of the address information.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when the Information Source requires this information to identify the Dependent for subsequent EDI transactions (see Section 1.4.7) unless a rejection response is generated. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Dependent Address Line

Use this information for the second line of the address information.

N4 - DEPENDENT CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Do not return address information from the 270 request unless the transaction is rejected and the rejection was caused by the address and this segment was present in the 270. See Section 1.4.7.1 271 item 7 for additional information.
Use this segment to identify address information for a dependent.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Dependent City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

INDUSTRY NAME: Dependent Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Dependent Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

AAA - DEPENDENT REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request could not be processed at a system or application level when specifically related to the data contained in the original 270 transaction's dependent name loop (Loop 2100D) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to indicate problems in processing the transaction specifically related to the data contained in the original 270 transaction's dependent name loop (Loop 2100D).

TR3 Example:

AAA✱N✱✱58✱C~

AAA

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Yes

Not Used

559

Agency Qualifier Code

O 1

Required

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.
Use codes "43", "45", "47", "48", or "51" only in response to information that is in or should be in the PRV segment in the Dependent Name loop (2100D).
See section 1.4.8 Search Options for data content criteria for the dependent.

CODE

DEFINITION

Required application data missing

Out of Network

Use this code to indicate that the dependent is not in the Network of the provider identified in the 2100B NM1 segment, or the 2100B/2100D PRV segment if present, in the 270 transaction.

Unable to Respond at Current Time

Invalid/Missing Provider Identification

Invalid/Missing Provider Specialty

Invalid/Missing Provider State

Invalid/Missing Referring Provider Identification Number

Provider is Not Primary Care Physician

Provider Not on File

Service Dates Not Within Provider Plan Enrollment

Inappropriate Date

Invalid/Missing Date(s) of Service

Invalid/Missing Date-of-Birth

Code 58 may not be returned if the information source has located an individual and the Birth Date does not match; use code 71 instead.

Date of Birth Follows Date(s) of Service

Date of Death Precedes Date(s) of Service

Date of Service Not Within Allowable Inquiry Period

Date of Service in Future

Invalid/Missing Patient ID

Invalid/Missing Patient Name

Required when the transaction was rejected when the information source cannot find a match for the Patient Name submitted or if the Patient Name was missing.

Invalid/Missing Patient Gender Code

Patient Not Found

Code 67 may not be returned if the information receiver submitted all four pieces of the mandated search option.

Duplicate Patient ID Number

Patient Birth Date Does Not Match That for the Patient on the Database

Code 71 must be returned when the transaction was rejected when the information source located an individual based other information submitted, but the Birth Date does not match.

Subscriber Found, Patient Not Found

Required

889

Follow-up Action Code

O 1

Code identifying follow-up actions allowed

Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Use only when AAA03 is "42".

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

Please Wait 10 Days and Resubmit

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

Use only when AAA03 is "42".

PRV - PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the 270 request contained a 2100D PRV segment and the information contained in the PRV segment was used to determine the 271 response.;
OR
Required when needed either to identify a provider's role or to associate a specialty type related to the service identified in the 2110D loop. This PRV segment applies to all benefits in this 2100D loop unless overridden by a PRV segment in the 2120D loop.
If not required by this implementation guide, do not send.

TR3 Notes:

If identifying a specific provider, use this segment to convey specific information about a provider's role in the eligibility/benefit being inquired about or to convey the provider's Taxonomy Code when the provider is not the information receiver. For example, if the information receiver is a hospital and a referring provider must be identified, this is the segment where the referring provider would be identified.
If identifying a type of specialty associated with the services identified in loop 2110D, use code PXC in PRV02 and the appropriate code in PRV03.
If there is a PRV segment in 2100B, this PRV overrides it for this occurrence of the 2100D loop.

TR3 Example:

PRV✱RF✱PXC✱207Q00000X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Attending

Billing

Consulting

Covering

Hospital

Home Health Care

Laboratory

Other Physician

Pharmacist

Pharmacy

Primary Care Physician

Performing

Rural Health Clinic

Referring

Skilled Nursing Facility

Supervising

Situational

128

Reference Identification Qualifier

O 1

2/3

Code qualifying the Reference Identification

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when needed to identify a provider's specialty type. If not required by this implementation guide, do not send.

If this segment is used to identify a type of specialty associated with the services identified in loop 2110D, use code PXC.

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Situational

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

SITUATIONAL RULE: Required when needed to identify a provider's specialty type. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Identifier

Use this number for the reference number as qualified by the preceding data element (PRV02).

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

DMG*D8 - DEPENDENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

P0102
If either DMG01 or DMG02 is present, then the other is required.
P1011
If either DMG10 or DMG11 is present, then the other is required.
C1105
If DMG11 is present, then DMG05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Dependent is the patient unless a rejection response is generated with a 2100D or 2110D AAA segment and this segment was not sent in the request. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

TR3 Notes:

Use this segment to convey the birth date or gender demographic information for the dependent.

TR3 Example:

DMG✱D8✱19750616✱M~

DMG

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Situational

1250

Date Time Period Format Qualifier

O 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when Dependent Birth Date is sent in DMG02. If not required by this implementation guide, do not send.

Use this code to indicate the format of the date of birth that follows in DMG02.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

1251

Date Time Period

O 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when the Dependent is the patient unless a rejection response is generated with a 2100D or 2110D AAA segment and this element was not sent in the request. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Dependent Birth Date

Use this date for the date of birth of the dependent.

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

INDUSTRY NAME: Dependent Gender Code

CODE

DEFINITION

Female

Male

Unknown

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

O 10

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

O 1

1/3

Not Used

1271

Industry Code

O 1

1/30

INS*N - DEPENDENT RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit information on insured entities

X12 Syntax:

P1112
If either INS11 or INS12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

This segment may also be used to identify that the information source has changed some of the identifying elements for the dependent that the information receiver submitted in the original 270 transaction.

TR3 Example:

INS✱N✱19✱✱✱✱✱✱✱✱✱✱✱✱✱✱✱3~

INS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

CODE

DEFINITION

Spouse

Child

Employee

Unknown

Use this code if the relationship code of Unknown is valid for this person when received in the 837 2000C PAT01
OR
Use this code if relationship information is not available and there is a need to use data elements INS03, INS04, or INS17.

Organ Donor

Cadaver Donor

Life Partner

Other Relationship

Situational

875

Maintenance Type Code

O 1

Code identifying the specific type of item maintenance

SITUATIONAL RULE: Required along with INS04 when acknowledging a change in the identifying elements for the dependent from those submitted in the 270. If not required by this implementation guide, do not send.

Use this element (and code "25" in INS04) if any of the identifying elements for the dependent have been changed from those submitted in the 270.

CODE

DEFINITION

001

Change

Situational

1203

Maintenance Reason Code

O 1

2/3

Code identifying the reason for the maintenance change

SITUATIONAL RULE: Required along with INS03 when acknowledging a change in the identifying elements for the dependent from those submitted in the 270. If not required by this implementation guide, do not send.

Use this element (and code "001" in INS03) if any of the identifying elements for the dependent have been changed from those submitted in the 270.

CODE

DEFINITION

Change in Identifying Data Elements

Use this code to indicate that a change has been made to the primary elements that identify a specific person. Such elements are first name, last name, date of birth, and identification numbers.

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Not Used

584

Employment Status Code

O 1

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Situational

1470

Number

O 1

1/9

A generic number

SITUATIONAL RULE: Required when the Birth Sequence Number submitted in the 270 was used to locate the Dependent. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Birth Sequence Number

Use to indicate the birth order in the event of multiple births in association with the birth date supplied in DMG02.

HI - DEPENDENT HEALTH CARE DIAGNOSIS CODE

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an HI segment was received in the 270 and if the information source uses the information in the determination of the eligibility or benefit response for the dependent. All information used from the HI segment of the 270 used in the determination of the eligibility or benefit response for the dependent must be returned. If information was provided in an HI segment of 270 but was not used in the determination of the eligibility or benefits for the dependent it must not be returned. The information source must not use information in an HI segment of the 270 transaction in the determination of eligibility or benefits for the dependent if that information cannot be returned in the 271 response.
OR
Required when needed to identify limitations in the benefits identified in the 2110D loops, such as if benefits are limited for a specific diagnosis code if the information source can support this high level functionality. If the information source cannot support this high level functionality, do not send.

TR3 Notes:

Use the Diagnosis code pointers in 2110D EB14 to identify which diagnosis code or codes in this HI segment relates to the information provided in the EB segment.
Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.

TR3 Example:

HI✱BK:8901✱BF:87200✱BF:5559~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

E codes are Not Used in HI01 except when defined by the claims processor. E codes may be put in any other HI element using BF as the qualifier.
The diagnosis listed in this element is assumed to be the principal diagnosis.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABK

International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

1-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1-4

1251

Date Time Period

O 1

1/35

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

O 1

1/30

Not Used

1-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

2-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

2-4

1251

Date Time Period

O 1

1/35

Not Used

2-5

782

Monetary Amount

O 1

1/18

Not Used

2-6

380

Quantity

O 1

1/15

Not Used

2-7

799

Version Identifier

O 1

1/30

Not Used

2-8

1271

Industry Code

O 1

1/30

Not Used

2-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

3-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

3-4

1251

Date Time Period

O 1

1/35

Not Used

3-5

782

Monetary Amount

O 1

1/18

Not Used

3-6

380

Quantity

O 1

1/15

Not Used

3-7

799

Version Identifier

O 1

1/30

Not Used

3-8

1271

Industry Code

O 1

1/30

Not Used

3-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

4-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

4-4

1251

Date Time Period

O 1

1/35

Not Used

4-5

782

Monetary Amount

O 1

1/18

Not Used

4-6

380

Quantity

O 1

1/15

Not Used

4-7

799

Version Identifier

O 1

1/30

Not Used

4-8

1271

Industry Code

O 1

1/30

Not Used

4-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

5-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

5-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

5-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

5-4

1251

Date Time Period

O 1

1/35

Not Used

5-5

782

Monetary Amount

O 1

1/18

Not Used

5-6

380

Quantity

O 1

1/15

Not Used

5-7

799

Version Identifier

O 1

1/30

Not Used

5-8

1271

Industry Code

O 1

1/30

Not Used

5-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

6-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

6-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

6-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

6-4

1251

Date Time Period

O 1

1/35

Not Used

6-5

782

Monetary Amount

O 1

1/18

Not Used

6-6

380

Quantity

O 1

1/15

Not Used

6-7

799

Version Identifier

O 1

1/30

Not Used

6-8

1271

Industry Code

O 1

1/30

Not Used

6-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

7-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

7-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

7-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

7-4

1251

Date Time Period

O 1

1/35

Not Used

7-5

782

Monetary Amount

O 1

1/18

Not Used

7-6

380

Quantity

O 1

1/15

Not Used

7-7

799

Version Identifier

O 1

1/30

Not Used

7-8

1271

Industry Code

O 1

1/30

Not Used

7-9

1073

Yes/No Condition or Response Code

O 1

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.

Required

8-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Required

8-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

8-3

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

8-4

1251

Date Time Period

O 1

1/35

Not Used

8-5

782

Monetary Amount

O 1

1/18

Not Used

8-6

380

Quantity

O 1

1/15

Not Used

8-7

799

Version Identifier

O 1

1/30

Not Used

8-8

1271

Industry Code

O 1

1/30

Not Used

8-9

1073

Yes/No Condition or Response Code

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

DTP - DEPENDENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required to identify the Plan (DTP01 = 291) or Plan Begin (DTP01 = 346) date when the individual has active coverage unless multiple plans apply to the individual or multiple plan periods apply, which must then be returned in the 2110D DTP (See Section 1.4.7);
OR
Required when needed to identify other relevant dates that apply to the Dependent.
If not required by this implementation guide, do not send.

TR3 Notes:

The dates represented may be in the past, the current date, or a future date. The dates may also be a single date or a span of dates. Which date(s) to use is determined by the format qualifier in DTP02.
Dates supplied in the 2100D DTP apply to the Dependent and all 2110D loops unless overridden by an occurrence of a 2110D DTP with the same value in DTP01.

TR3 Example:

DTP✱346✱D8✱19950818~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

096

Discharge

102

Issue

152

Effective Date of Change

291

Plan

307

Eligibility

318

Added

Information Sources are encouraged to return Added date in the case of retroactive eligibility.

340

Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin

341

Consolidated Omnibus Budget Reconciliation Act (COBRA) End

342

Premium Paid to Date Begin

343

Premium Paid to Date End

346

Plan Begin

347

Plan End

356

Eligibility Begin

357

Eligibility End

382

Enrollment

435

Admission

442

Date of Death

458

Certification

472

Service

539

Policy Effective

540

Policy Expiration

636

Date of Last Update

771

Status

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

Use this code to specify the format of the date(s)/time(s) that follow in the next data element.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

Use this date for the date(s) as qualified by the preceding data elements.

MPI - DEPENDENT MILITARY PERSONNEL INFORMATION

X12 Name:

Military Personnel Information

X12 Purpose:

To report military service data

X12 Syntax:

P0607
If either MPI06 or MPI07 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this transaction is processed by DOD or CHAMPUS/TRICARE and when necessary to convey the Dependent's military service data If not required by this implementation guide, do not send.

TR3 Example:

MPI✱C✱AO✱A✱✱L3~Current Active Military - Overseas Air Force Lieutenant Colonel

MPI

✱

1201

Information
Status Code

✱

✱

1595

Gov. Serv.
Affil. Code

✱

✱

✱

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

✱

Required

1201

Information Status Code

M 1

A code to indicate the status of information

CODE

DEFINITION

Partial

Current

Latest

Oldest

Prior

Second Most Current

Third Most Current

Required

584

Employment Status Code

M 1

Code showing the general employment status of an employee/claimant

CODE

DEFINITION

Active Reserve

Active Military - Overseas

Academy Student

Presidential Appointee

Active Military - USA

Contractor

Dishonorably Discharged

Honorably Discharged

Inactive Reserves

Leave of Absence: Military

Plan to Enlist

Recommissioned

Retired Military - Overseas

Retired Without Recall

Retired Military - USA

Required

1595

Government Service Affiliation Code

M 1

Code specifying the government service affiliation

CODE

DEFINITION

Air Force

Air Force Reserves

Army

Army Reserves

Coast Guard

Marine Corps

Marine Corps Reserves

National Guard

Navy

Navy Reserves

Other

Peace Corp

Regular Armed Forces

Reserves

U.S. Public Health Service

Foreign Military

American Red Cross

Department of Defense

United Services Organization

Military Sealift Command

Situational

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SEMANTIC: MPI04 is the actual response to further identify the exact military unit.

SITUATIONAL RULE: Required when needed to further identify the exact military unit. If not required by this implementation guide, do not send.

Situational

1596

Military Service Rank Code

O 1

Code specifying the military service rank

SITUATIONAL RULE: Required when needed to indicate the current or most recent military service rank. If not required by this implementation guide, do not send.

CODE

DEFINITION

Admiral

Airman

Airman First Class

Basic Airman

Brigadier General

Captain

Chief Master Sergeant

Chief Petty Officer

Chief Warrant

Colonel

Commander

Commodore

Corporal

Corporal Specialist 4

Ensign

First Lieutenant

First Sergeant

First Sergeant-Master Sergeant

Fleet Admiral

General

Gunnery Sergeant

Lance Corporal

Lieutenant

Lieutenant Colonel

Lieutenant Commander

Lieutenant General

Lieutenant Junior Grade

Major

Major General

Master Chief Petty Officer

Master Gunnery Sergeant Major

Master Sergeant

Master Sergeant Specialist 8

Petty Officer First Class

Petty Officer Second Class

Petty Officer Third Class

Private

Private First Class

Rear Admiral

Recruit

Seaman

Seaman Apprentice

Seaman Recruit

Second Lieutenant

Senior Chief Petty Officer

Senior Master Sergeant

Sergeant

Sergeant First Class Specialist 7

Sergeant Major Specialist 9

Sergeant Specialist 5

Staff Sergeant

Staff Sergeant Specialist 6

Technical Sergeant

Vice Admiral

Warrant Officer

Situational

1250

Date Time Period Format Qualifier

O 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0607

SITUATIONAL RULE: Required when needed to indicate the beginning date or date span of military service. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

1251

Date Time Period

O 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEMANTIC: MPI07 indicates the date span of military service.

SEGMENT SYNTAX: P0607

SITUATIONAL RULE: Required when needed to indicate the beginning date or date span of military service. If not required by this implementation guide, do not send.

EB - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

X12 Name:

Eligibility or Benefit Information

X12 Purpose:

To supply eligibility or benefit information

X12 Syntax:

P0910
If either EB09 or EB10 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the dependent is the person whose eligibility or benefits are being described and the transaction is not rejected (see Section 1.4.10) or if the transaction needs to be rejected in this loop. If not required by this implementation guide, do not send.

TR3 Notes:

See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what information must be returned if the subscriber is the person whose eligibility or benefits are being sent.
Either EB03 or EB13 may be used in the same EB segment, not both.
EB03 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110D loop is the same with the exception of the Service Type Code used in EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110D loop are identical.
A limit to the number of repeats of EB loops has not been established. In a batch environment there is no practical reason to limit the number of EB loop repeats. In a real time environment, consideration should be given to how many EB loops are generated given the amount of time it takes to format the response and the amount of time it will take to transmit that response. Since these limitations will vary by information source, it would be completely arbitrary for the developers to set a limit. It is not the intent of the developers to limit the amount of information that is returned in a response, rather to alert information sources to consider the potential delays if the response contains too much information to be formatted and transmitted in real time.
Use this segment to begin the eligibility/benefit information looping structure. The EB segment is used to convey the specific eligibility or benefit information for the entity identified.

TR3 Example:

EB✱1✱FAM✱96✱GP~Active Coverage for subscriber and family, for Professional (Physician) services, and coverage is through a Group Policy
EB✱B✱✱68✱✱✱27✱10~Co-payment for Well Baby Care is $10 per visit
EB✱C✱FAM✱✱✱✱23✱600~Deductible for the family is $600 per calendar year
EB✱L~Primary Care Provider (information about the Primary Care Provider will be located in the 2120 loop)
EB✱A✱✱A6✱✱✱✱✱.50~Co-Insurance is 50 percent for Psychotherapy
EB✱B✱✱98^34^44^81^A0^A3✱✱✱✱10✱✱VS✱1~Co-payment for Professional (Physician) Visit - Office, Chiropractic Office Visits, Home Health Visits, Routine Physical, Professional (Physician) Visit - Outpatient, Professional (Physician) Visit - Home, is $10 for one visit

✱

1390

Eligibility
Benefit Inf

✱

✱

✱

✱

Plan Cvrg
Description

1/50

✱

615

✱

✱

✱

✱

✱

✱

✱

C003

✱

C004

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

Required

1390

Eligibility or Benefit Information Code

M 1

1/2

Code identifying eligibility or benefit information

SEMANTIC: EB01 qualifies EB06 through EB10.

INDUSTRY NAME: Eligibility or Benefit Information

Use this code to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category that is being further described in the following data elements. This data element also qualifies the data in elements EB06 through EB10.
If codes A, B, C, G, J or Y are used, it is required that the patient's portion of responsibility is reflected in either EB07 or EB08. See Section 1.4.9 Patient Responsibility for detailed information and definitions.

OPERATING RULE REQUIREMENTS: The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule EB.1.0 (URL) requires the information source to:

Return the coverage status of all explicit service types, regardless of whether that status is separate and distinct from the plan coverage. This includes coverage of service types for which financial reporting is discretionary. (1.3.2.4)
If coverage is active, return the base and remaining deductible, co-payment, and co-insurance patient responsibility details for the health plan (service type code 30), as well as for explicit service types, if the patient financials are different from the plan coverage (Sections 1.3.2.5 through 1.3.2.8).
Remaining deductibles must be reported only if the 270 inquiry is for the current time period (Section 1.3.2.6.2).

CODE

DEFINITION

Active Coverage

Active - Full Risk Capitation

Active - Services Capitated

Active - Services Capitated to Primary Care Physician

Active - Pending Investigation

Inactive

Inactive - Pending Eligibility Update

Inactive - Pending Investigation

Co-Insurance

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Co-Payment

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Deductible

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Coverage Basis

Benefit Description

Exclusions

Limitations

Out of Pocket (Stop Loss)

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Unlimited

Non-Covered

Cost Containment

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Reserve

Primary Care Provider

Pre-existing Condition

Managed Care Coordinator

Services Restricted to Following Provider

Not Deemed a Medical Necessity

Benefit Disclaimer

Not recommended. See section 1.4.11 Disclaimers Within the Transaction.

Second Surgical Opinion Required

Other or Additional Payor

Prior Year(s) History

Card(s) Reported Lost/Stolen

Code "T" is typically used by Medicaids to indicate to a provider that the person who has presented the ID card is using a stolen ID card.

Contact Following Entity for Eligibility or Benefit Information

Cannot Process

Other Source of Data

Health Care Facility

Spend Down

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

Situational

1207

Coverage Level Code

O 1

Code indicating the level of coverage being provided for this insured

SITUATIONAL RULE: Required when needed to identify the types of individuals associated with the eligibility or benefits being identified in the 2110D loop. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Coverage Level Code

CODE

DEFINITION

CHD

Children Only

DEP

Dependents Only

ECH

Employee and Children

ESP

Employee and Spouse

FAM

Family

IND

Individual

SPC

Spouse and Children

SPO

Spouse Only

Situational

1365

Service Type Code

O 99

1/2

Code identifying the classification of service

SEMANTIC: Position of data in the repeating data element conveys no significance.

SITUATIONAL RULE: Required when the dependent is the patient and has been found in the Information Source's system to identify Active or Inactive Health Benefit Plan Coverage (See Section 1.4.7);ORRequired when one of the Service Type Codes identified in Section 1.4.7 must be returned;ORRequired when responding to a corresponding Service Type code used from the 270 transaction;ORRequired when the eligibility or benefits being identified in the 2110D loop need to be associated with a specific Service Type Code.If not required by this implementation guide or if EB13 is used, do not send.

See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what service type codes must be returned.
EB03 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110D loop is the same with the exception of the Service Type Code used in EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110D loop are identical.
Not used if EB13 is present.

CODE

DEFINITION

Medical Care

Surgical

Consultation

Diagnostic X-Ray

Diagnostic Lab

Radiation Therapy

Anesthesia

Surgical Assistance

Other Medical

Blood Charges

Used Durable Medical Equipment

Durable Medical Equipment Purchase

Ambulatory Service Center Facility

Renal Supplies in the Home

Alternate Method Dialysis

Chronic Renal Disease (CRD) Equipment

Pre-Admission Testing

Durable Medical Equipment Rental

Pneumonia Vaccine

Second Surgical Opinion

Third Surgical Opinion

Social Work

Diagnostic Dental

Periodontics

Restorative

Endodontics

Maxillofacial Prosthetics

Adjunctive Dental Services

Health Benefit Plan Coverage

See Section 1.4.7.1

Plan Waiting Period

Chiropractic

Chiropractic Office Visits

Dental Care

Dental Crowns

Dental Accident

Orthodontics

Prosthodontics

Oral Surgery

Routine (Preventive) Dental

Home Health Care

Home Health Prescriptions

Home Health Visits

Hospice

Respite Care

Hospital

Hospital - Inpatient

Hospital - Room and Board

Hospital - Outpatient

Hospital - Emergency Accident

Hospital - Emergency Medical

Hospital - Ambulatory Surgical

Long Term Care

Major Medical

Medically Related Transportation

Air Transportation

Cabulance

Licensed Ambulance

General Benefits

In-vitro Fertilization

MRI/CAT Scan

Donor Procedures

Acupuncture

Newborn Care

Pathology

Smoking Cessation

Well Baby Care

Maternity

Transplants

Audiology Exam

Inhalation Therapy

Diagnostic Medical

Private Duty Nursing

Prosthetic Device

Dialysis

Otological Exam

Chemotherapy

Allergy Testing

Immunizations

Routine Physical

Family Planning

Infertility

Abortion

AIDS

Emergency Services

Cancer

Pharmacy

Free Standing Prescription Drug

Mail Order Prescription Drug

Brand Name Prescription Drug

Generic Prescription Drug

Podiatry

Podiatry - Office Visits

Podiatry - Nursing Home Visits

Professional (Physician)

Anesthesiologist

Professional (Physician) Visit - Office

Professional (Physician) Visit - Inpatient

Professional (Physician) Visit - Outpatient

Professional (Physician) Visit - Nursing Home

Professional (Physician) Visit - Skilled Nursing Facility

Professional (Physician) Visit - Home

Psychiatric

Psychiatric - Room and Board

Psychotherapy

Psychiatric - Inpatient

Psychiatric - Outpatient

Rehabilitation

Rehabilitation - Room and Board

Rehabilitation - Inpatient

Rehabilitation - Outpatient

Occupational Therapy

Physical Medicine

Speech Therapy

Skilled Nursing Care

Skilled Nursing Care - Room and Board

Substance Abuse

Alcoholism

Drug Addiction

Vision (Optometry)

Frames

Routine Exam

Use for Routine Vision Exam only.

Lenses

Nonmedically Necessary Physical

Experimental Drug Therapy

Burn Care

Brand Name Prescription Drug - Formulary

Brand Name Prescription Drug - Non-Formulary

Independent Medical Evaluation

Partial Hospitalization (Psychiatric)

Day Care (Psychiatric)

Cognitive Therapy

Massage Therapy

Pulmonary Rehabilitation

Cardiac Rehabilitation

Pediatric

Nursery

Skin

Orthopedic

Cardiac

Lymphatic

Gastrointestinal

Endocrine

Neurology

Eye

Invasive Procedures

Gynecological

Obstetrical

Obstetrical/Gynecological

Mail Order Prescription Drug: Brand Name

Mail Order Prescription Drug: Generic

Physician Visit - Office: Sick

Physician Visit - Office: Well

Coronary Care

Private Duty Nursing - Inpatient

Private Duty Nursing - Home

Surgical Benefits - Professional (Physician)

Surgical Benefits - Facility

Mental Health Provider - Inpatient

Mental Health Provider - Outpatient

Mental Health Facility - Inpatient

Mental Health Facility - Outpatient

Substance Abuse Facility - Inpatient

Substance Abuse Facility - Outpatient

Screening X-ray

Screening laboratory

Mammogram, High Risk Patient

Mammogram, Low Risk Patient

Flu Vaccination

Eyewear and Eyewear Accessories

Case Management

Dermatology

Durable Medical Equipment

Diabetic Supplies

Generic Prescription Drug - Formulary

Generic Prescription Drug - Non-Formulary

Allergy

Intensive Care

Mental Health

Neonatal Intensive Care

Oncology

Physical Therapy

Pulmonary

Renal

Residential Psychiatric Treatment

Transitional Care

Transitional Nursery Care

Urgent Care

Situational

1336

Insurance Type Code

O 1

1/3

Code identifying the type of insurance policy within a specific insurance program

SITUATIONAL RULE: Required when the Information Source requires the Dependent's Insurance Type Code for subsequent EDI transactions (see Section 1.4.7). If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

CODE

DEFINITION

Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan

Medicare Secondary, No-fault Insurance including Auto is Primary

Medicare Secondary Worker's Compensation

Medicare Secondary Public Health Service (PHS)or Other Federal Agency

Medicare Secondary Black Lung

Medicare Secondary Veteran's Administration

Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)

Medicare Secondary, Other Liability Insurance is Primary

Auto Insurance Policy

Commercial

Consolidated Omnibus Budget Reconciliation Act (COBRA)

Medicare Conditionally Primary

Disability

Disability Benefits

Exclusive Provider Organization

Family or Friends

Group Policy

Health Maintenance Organization (HMO)

Health Maintenance Organization (HMO) - Medicare Risk

Special Low Income Medicare Beneficiary

Indemnity

Individual Policy

Long Term Care

Long Term Policy

Life Insurance

Litigation

Medicare Part A

Medicare Part B

Medicaid

Medigap Part A

Medigap Part B

Medicare Primary

Other

When this code is returned by Medicare or a Medicare Part D administrator, this code indicates a type of insurance of Medicare Part D.

Property Insurance - Personal

Personal

Personal Payment (Cash - No Insurance)

Preferred Provider Organization (PPO)

Point of Service (POS)

Qualified Medicare Beneficiary

Property Insurance - Real

Supplemental Policy

Tax Equity Fiscal Responsibility Act (TEFRA)

Workers Compensation

Wrap Up Policy

Situational

1204

Plan Coverage Description

O 1

1/50

A description or number that identifies the plan or coverage

SITUATIONAL RULE: Required when a specific Plan Name exists for the plan which the individual has coverage in conjunction with the 2110D loop with EB01 Status = 1, 2, 3, 4, 5, 6, 7 or 8 and EB03 Service Type Code = 30 (See Section 1.4.7). If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.

This element is to be used only to convey the specific product name for an insurance plan. For example, if a plan has a brand name, such as "Gold 1-2-3", the name may be placed in this element. This element must not to be used to give benefit details of a plan.

Situational

615

Time Period Qualifier

O 1

1/2

Code defining periods

SITUATIONAL RULE: Required when the availability of the eligibility or benefits being identified in the 2110D loop need to be qualified by a time period. If not required by this implementation guide, do not send.

CODE

DEFINITION

Hour

Day

24 Hours

Years

Service Year

Calendar Year

Year to Date

Contract

Episode

Visit

Outlier

Remaining

Exceeded

Not Exceeded

Lifetime

Lifetime Remaining

Month

Week

Admission

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SITUATIONAL RULE: Required when EB01 = B, C, G, J or Y. Do not use if EB01 = A. May be used at the sender's discretion for other EB01 values. May not be a negative number.

INDUSTRY NAME: Benefit Amount

Use this monetary amount as qualified by EB01.
When EB01 = B, C, G, J or Y, the amount represents the Patient's portion of responsibility. See Section 1.4.9 Patient Responsibility.
Use if eligibility or benefit must be qualified by a monetary amount; e.g., deductible, co-payment.

Situational

954

Percentage as Decimal

O 1

1/10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

SITUATIONAL RULE: Required when EB01 = A. Do not use if EB01 = B, C, G, J or Y. May be used at the sender's discretion for other EB01 values. May not be a negative number.

INDUSTRY NAME: Benefit Percent

Use this percentage rate as qualified by EB01.
When EB01 = A, the amount represents the Patient's portion of responsibility. See Section 1.4.9 Patient Responsibility.
Use if eligibility or benefit must be qualified by a percentage; e.g., co-insurance.

Situational

673

Quantity Qualifier

O 1

Code specifying the type of quantity

SEGMENT SYNTAX: P0910

SITUATIONAL RULE: Required when needed to further qualify the eligibility or benefits being identified in the 2110D loop by quantity. If not required by this implementation guide, do not send.

Use this code to identify the type of units that are being conveyed in the following data element (EB10).

CODE

DEFINITION

Minimum

Quantity Used

Covered - Actual

Covered - Estimated

Number of Co-insurance Days

Deductible Blood Units

Days

Hours

Life-time Reserve - Actual

Life-time Reserve - Estimated

Maximum

Month

Number of Services or Procedures

Quantity Approved

Age, High Value

Use this code when a benefit is based on a maximum age for the patient.

Age, Low Value

Use this code when a benefit is based on a minimum age for the patient.

Visits

Years

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0910

SITUATIONAL RULE: Required when needed to further qualify the eligibility or benefits being identified in the 2110D loop by quantity. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Quantity

Use this number for the quantity value as qualified by the preceding data element (EB09).

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SITUATIONAL RULE: Required when needed to indicate if authorization or certification is required for the eligibility or benefits being identified in the 2110D loop. If not required by this implementation guide, do not send.

INDUSTRY NAME: Authorization or Certification Indicator

CODE

DEFINITION

Unknown

Yes

Situational

1073

Yes/No Condition or Response Code

O 1

Code indicating a Yes or No condition or response

SITUATIONAL RULE: Required when needed to indicate if benefits are considered In Plan Network or Out Of Plan Network for the eligibility or benefits being identified in the 2110D loop. If not required by this implementation guide, do not send.

INDUSTRY NAME: In Plan Network Indicator

CODE

DEFINITION

Unknown

Not Applicable

Use code "W" - Not Applicable when benefits are the same regardless of whether they are In Plan-Network or Out of Plan-Network or a Plan-Network does not apply to the benefit.

Yes

Situational

C003

Composite Medical Procedure Identifier

O 1

To identify a medical procedure by its standardized codes and applicable modifiers

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.

SITUATIONAL RULE: Required when a Medical Procedure Code was used from the 270 to determine the response being identified in the 2110D loop;ORRequired when the Information Source supports Medical Procedure Code based 271 transactions and a Medical Procedure Code is available and appropriate for the eligibility or benefits being identified in the 2110D loop.If not required by this implementation guide or if EB03 is used, do not send.

Use this composite data element only if an information source can support this high level of functionality. The EB13 allows for a very specific response.
Not used if EB03 is present.

Required

13-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

Use this code to identify the external code list of the following procedure/service code.

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Current Procedural Terminology (CPT) Codes

CODE SOURCE: 133: Current Procedural Terminology (CPT) Codes

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

CODE SOURCE: 130: Healthcare Common Procedure Coding System

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE: 513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Mutually Defined

Required

13-2

234

Product/Service ID

M 1

1/48

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Use this ID number for the product/service code as qualified by the preceding data element.

Situational

13-3

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a modifier was used from the 270 to determine the response being identified in the 2110D loop;ORRequired when a modifier clarifies/improves the accuracy of the associated procedure code and the modifier is available.If not required by this implementation guide, do not send.

Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.

Situational

13-4

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.

Situational

13-5

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.

Situational

13-6

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.

Not Used

13-7

352

Description

O 1

1/80

Situational

13-8

234

Product/Service ID

O 1

1/48

Identifying number for a product or service

SITUATIONAL RULE: Required when the Information Source desires to indicate a range of procedure codes. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

EB13-2 indicates the beginning of value of the range of procedure codes and EB13-8 represents the end of the range of procedure codes. All procedure codes in the range will apply.

Situational

C004

Composite Diagnosis Code Pointer

O 1

To identify one or more diagnosis code pointers

X12 COMPOSITE SEMANTIC NOTES:

C004-01 identifies the primary diagnosis code for this service line.
C004-02 identifies the second diagnosis code for this service line.
C004-03 identifies the third diagnosis code for this service line.
C004-04 identifies the fourth diagnosis code for this service line.

SITUATIONAL RULE: Required when a 2100D HI segment is used and the information in this 2110D EB loop is related to a diagnosis code. If 2100D HI segment is not used or if the information in this 2110D EB loop is not related to a diagnosis code, do not send.

See requirements for the use of the 2100D HI segment for additional information.

Required

14-1

1328

Diagnosis Code Pointer

M 1

1/2

A pointer to the diagnosis code in the order of importance to this service

Situational

14-2

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a second diagnosis related to this EB segment. If not required, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.

Situational

14-3

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a third diagnosis related to this EB segment. If not required, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.

Situational

14-4

1328

Diagnosis Code Pointer

O 1

1/2

A pointer to the diagnosis code in the order of importance to this service

SITUATIONAL RULE: Required when it is necessary to designate a fourth diagnosis related to this EB segment. If not required, do not send.

Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.

HSD - HEALTH CARE SERVICES DELIVERY

X12 Name:

Health Care Services Delivery

X12 Purpose:

To specify the delivery pattern of health care services

X12 Syntax:

P0102
If either HSD01 or HSD02 is present, then the other is required.
C0605
If HSD06 is present, then HSD05 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to identify a specific delivery or usage pattern associated with the benefits identified in either EB03 or EB13. If not required by this implementation guide, do not send.

TR3 Example:

HSD✱VS✱30✱✱✱22~Thirty visits per service year
HSD✱VS✱12✱WK✱3✱34✱1~Twelve visits, three visits per week, for 1 month.

HSD

✱

✱

✱

✱

✱

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

✱

✱

Ship/Del or
Calend Code

✱

Situational

673

Quantity Qualifier

O 1

Code specifying the type of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying type and quantity benefits identified. If not required by this implementation guide, do not send.

Required if HSD02 is used.

CODE

DEFINITION

Days

Units

Hours

Month

Visits

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying type and quantity benefits identified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Quantity

Required if HSD01 is used.

Situational

355

Unit or Basis for Measurement Code

O 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

Months

Visit

Week

Years

Situational

1167

Sample Selection Modulus

O 1

1/6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

Situational

615

Time Period Qualifier

O 1

1/2

Code defining periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

CODE

DEFINITION

Hour

Day

Years

Service Year

Calendar Year

Year to Date

Contract

Episode

Visit

Outlier

Remaining

Exceeded

Not Exceeded

Lifetime

Lifetime Remaining

Month

Week

Situational

616

Number of Periods

O 1

1/3

Total number of periods

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

INDUSTRY NAME: Period Count

Situational

678

Ship/Delivery or Calendar Pattern Code

O 1

1/2

Code which specifies the routine shipments, deliveries, or calendar pattern

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Frequency Code

CODE

DEFINITION

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

1st & 3rd Weeks of the Month

2nd & 4th Weeks of the Month

1st Working Day of Period

Last Working Day of Period

Monday through Friday

Monday through Saturday

Monday through Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Monday through Thursday

Immediately

As Directed

Daily Mon. through Fri.

1/2 Mon. & 1/2 Thurs.

1/2 Tues. & 1/2 Thurs.

1/2 Wed. & 1/2 Fri.

Once Anytime Mon. through Fri.

Tuesday through Friday

Monday, Tuesday and Thursday

Monday, Tuesday and Friday

Wednesday and Thursday

Monday, Wednesday and Thursday

Tuesday, Thursday and Friday

1/2 Tue. & 1/2 Fri.

1/2 Mon. & 1/2 Wed.

1/3 Mon., 1/3 Wed., 1/3 Fri.

Whenever Necessary

1/2 By Wed., Bal. By Fri.

None (Also Used to Cancel or Override a Previous Pattern)

Situational

679

Ship/Delivery Pattern Time Code

O 1

Code which specifies the time for routine shipments or deliveries

SITUATIONAL RULE: Required when needed to provide further information about the number and frequency of benefits. If not required by this implementation guide, do not send.

INDUSTRY NAME: Delivery Pattern Time Code

CODE

DEFINITION

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

As Directed

Any Shift

None (Also Used to Cancel or Override a Previous Pattern)

REF - DEPENDENT ADDITIONAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Information Source requires one or more of these additional identifiers for subsequent EDI transactions (see Section 1.4.7);
OR
Required when an additional identifier is associated with the eligibility or benefits being identified in the 2110D loop.
If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment for reference identifiers related only to the 2110D loop that it is contained in (e.g. Other or Additional Payer's identifiers).
Use this segment to identify other or additional reference numbers for the entity identified. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2110D loop.

TR3 Example:

REF✱G1✱653745725~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
Use "1W", "49", "F6", and "NQ" only in a 2110D loop with EB01 = "R".
Only one occurrence of each REF01 code value may be used in the 2110D loop.

CODE

DEFINITION

Plan Number

Group or Policy Number

Use this code only if it cannot be determined if the number is a Group Number or a Policy number. Use codes "IG" or "6P" when they can be determined.

Member Identification Number

Family Unit Number

Group Number

Referral Number

ALS

Alternative List ID

Allows the source to identify the list identifier of a list of drugs and its alternative drugs with the associated formulary status for the patient.

CLI

Coverage List ID

Allows the source to identify the list identifier of a list of drugs that have coverage limitations for the associated patient.

Health Insurance Claim (HIC) Number

Drug Formulary Number

Prior Authorization Number

Insurance Policy Number

Plan Network Identification Number

Medicaid Recipient Identification Number

Required

127

Reference Identification

O 1

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Dependent Eligibility or Benefit Identifier

Use this information for the reference number as qualified by the preceding data element (REF01).

Situational

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = "18", "6P" or "N6" and a name needs to be associated with the corresponding identifier. If not required by this implementation guide, do not send.

INDUSTRY NAME: Group, Insurance Policy or Plan Network Name

Not Used

C040

Reference Identifier

O 1

DTP - DEPENDENT ELIGIBILITY/BENEFIT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the individual has active coverage with multiple plans or multiple plan periods apply (See 2100D DTP segment);
OR
Required when needed to convey dates associated with the eligibility or benefits being identified in the 2110D loop.
If not required by this implementation guide, do not send.

TR3 Notes:

When using the DTP segment in the 2110D loop this date applies only to the 2110D Eligibility or Benefit Information (EB) loop in which it is located.

If a DTP segment with the same DTP01 value is present in the 2100D loop, the date is overridden for only this 2110D Eligibility or Benefit Information (EB) loop.

TR3 Example:

DTP✱472✱D8✱19960624~

DTP

✱

✱

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

096

Discharge

193

Period Start

194

Period End

198

Completion

290

Coordination of Benefits

291

Plan

Use code 291 only if multiple plans apply to the individual or multiple plan periods apply. Dates supplied in this DTP segment only apply to the 2110D loop in which it occurs.

292

Benefit

295

Primary Care Provider

304

Latest Visit or Consultation

307

Eligibility

318

Added

346

Plan Begin

Use code 346 only if multiple plans apply to the individual or multiple plan periods apply. Dates supplied in this DTP segment only apply to the 2110D loop in which it occurs.

348

Benefit Begin

349

Benefit End

356

Eligibility Begin

357

Eligibility End

435

Admission

472

Service

636

Date of Last Update

771

Status

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

Use this code to specify the format of the date(s)/time(s) that follow in the next data element.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Eligibility or Benefit Date Time Period

Use this date for the date(s) as qualified by the preceding data elements.

AAA - DEPENDENT REQUEST VALIDATION

X12 Name:

Request Validation

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the request could not be processed at a system or application level when specifically related to specific eligibility/benefit inquiry data contained in the original 270 transaction's dependent eligibility/benefit inquiry information loop (Loop 2110D) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to indicate problems in processing the transaction specifically related to specific eligibility/benefit inquiry data contained in the original 270 transaction's dependent eligibility/benefit inquiry information loop (Loop 2110D).

TR3 Example:

AAA✱N✱✱70✱C~

AAA

✱

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

✱

✱

✱

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.

INDUSTRY NAME: Valid Request Indicator

CODE

DEFINITION

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

Not Used

559

Agency Qualifier Code

O 1

Required

901

Reject Reason Code

O 1

Code assigned by issuer to identify reason for rejection

Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.

CODE

DEFINITION

Required application data missing

Input Errors

Service Dates Not Within Provider Plan Enrollment

Inquired Benefit Inconsistent with Provider Type

Inappropriate Product/Service ID Qualifier

Inappropriate Product/Service ID

Inappropriate Date

Invalid/Missing Date(s) of Service

Date of Birth Follows Date(s) of Service

Date of Death Precedes Date(s) of Service

Date of Service Not Within Allowable Inquiry Period

Date of Service in Future

Inconsistent with Patient's Age

Inconsistent with Patient's Gender

Experimental Service or Procedure

Authorization Number Not Found

Use this code only when the Referral Number or Prior Authorization Number in 2110D REF02 is not found.

Requires Primary Care Physician Authorization

Invalid/Missing Diagnosis Code(s)

Invalid/Missing Procedure Code(s)

Use this code for errors with Procedure Codes in EQ02-2 or Procedure Code Modifiers in EQ02-3 through EQ02-6.

Additional Patient Condition Information Required

Certification Information Does Not Match Patient

Use this code only when the Referral Number or Prior Authorization Number in 2110D REF02 is found but is not associated with the subscriber.

Requires Medical Review

Invalid Authorization Number Format

Use this code only when the Referral Number or Prior Authorization Number in 2110D REF02 is not formatted properly.

Missing Authorization Number

Use this code only when the Referral Number or Prior Authorization Number has been issued and is missing in 2110D REF02 but is needed to respond appropriately.

Required

889

Follow-up Action Code

O 1

Code identifying follow-up actions allowed

Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).

CODE

DEFINITION

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Please Wait 30 Days and Resubmit

Please Wait 10 Days and Resubmit

Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

MSG - MESSAGE TEXT

X12 Name:

Message Text

X12 Purpose:

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

X12 Syntax:

C0302
If MSG03 is present, then MSG02 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

Free form text or description fields are not recommended because they require human interpretation.
Under no circumstances can an information source use the MSG segment to relay information that can be sent using codified information in existing data elements (including combinations of multiple data elements and segments). Information that has been provided in codified form in other segments or elements elsewhere in the 271 for the individual must not be repeated in the MSG segment. If the information cannot be codified, then cautionary use of the MSG segment is allowed as a short term solution. It is highly recommended that the entity needing to use the MSG segment approach X12N with data maintenance to solve the long term business need, so the use of the MSG segment can be avoided for that issue.
Benefit Disclaimers are strongly discouraged. See section 1.4.11 Disclaimers Within the Transaction. Under no circumstances are more than one MSG segment to be used for a Benefit Disclaimer per individual response.

TR3 Example:

MSG✱Free form text is discouraged~

MSG

✱

933

Loop 2115D - DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION

✱

✱

Required

933

Free-form Message Text

M 1

1/264

Free-form message text

INDUSTRY NAME: Free Form Message Text

Not Used

934

Printer Carriage Control Code

O 1

Not Used

1470

Number

O 1

1/9

III - DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION

X12 Name:

Information

X12 Purpose:

To report information

X12 Syntax:

P0102
If either III01 or III02 is present, then the other is required.
L030405
If III03 is present, then at least one of III04 or III05 are required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when III segments in Loop 2110D of the 270 Inquiry were used in the determination of the eligibility or benefit response;
OR
Required when needed to identify limitations in the benefits explained in the corresponding Loop 2110D (such as if benefits are limited to a type of facility).
If not required by this implementation guide, do not send.

TR3 Notes:

This segment has two purposes. Information that was received in III segments in Loop 2110D of the 270 Inquiry and was used in the determination of the eligibility or benefit response must be returned. If information was provided in III segments of Loop 2110D but was not used in the determination of the eligibility or benefits it must not be returned. This segment can also be used to identify limitations in the benefits explained in the corresponding Loop 2110D, such as if benefits are limited to a type of facility.
Use this segment to identify Nature of Injury Codes and/or Facility Type as they relate to the information provided in the EB segment.
Use the III segment only if an information source can support this high level functionality.
Use this segment only one time for the Facility Type Code.

TR3 Example:

III✱ZZ✱21~III✱✱✱44✱Broken bones and third degree burns~

III

✱

✱

✱

✱

✱

✱

Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

✱

✱

✱

Situational

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying a Nature of Injury Code or a Facility Type Code. If not required by this implementation guide, do not send.

Use this code to specify if the code that is following in the III02 is a Nature of Injury Code or a Facility Type Code.

CODE

DEFINITION

National Council on Compensation Insurance (NCCI) Nature of Injury Code

CODE SOURCE: 284: Nature of Injury Code

Nature of Injury Code

Other code source as specified by the jurisdiction.

CODE SOURCE: 407: Occupational Injury and Illness Classification Manual

Mutually Defined

Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of Service Codes for Professional Claims.

Situational

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when identifying a Nature of Injury Code or a Facility Type Code. If not required by this implementation guide, do not send.

If III01 is GR, use this element for NCCI Nature of Injury code from code source 284.
If III01 is NI, use this element for Nature of Injury code from code source 407.
If III01 is ZZ, use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below, however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here.

01 Pharmacy
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-based Facility
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service

Situational

1136

Code Category

O 1

Specifies the situation or category to which the code applies

SEMANTIC: III03 is used to categorize III04.

SEGMENT SYNTAX: L030405

SITUATIONAL RULE: Required when III01 and III02 are not present or if additional information is needed (see III04). If not required by this implementation guide or if III01 is ZZ, do not send.

CODE

DEFINITION

Nature of Injury

Situational

933

Free-form Message Text

O 1

1/264

Free-form message text

SEGMENT SYNTAX: L030405

SITUATIONAL RULE: Required when III03 = "44". If not required by this implementation guide, do not send.

INDUSTRY NAME: Injured Body Part Name

Not Used

380

Quantity

O 1

1/15

Not Used

C001

Composite Unit of Measure

O 1

Not Used

752

Surface/Layer/Position Code

O 1

Not Used

752

Surface/Layer/Position Code

O 1

Not Used

752

Surface/Layer/Position Code

O 1

LS - LOOP HEADER

X12 Name:

Loop Header

X12 Purpose:

To indicate that the next segment begins a loop

X12 Comments:

See Figures Appendix for an explanation of the use of the LS and LE segments.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when Loop 2120D is used. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to identify the beginning of the Dependent Benefit Related Entity Name loop. Because both the subscriber's name loop and this loop begin with NM1 segments, the LS and LE segments are used to differentiate these two loops.

TR3 Example:

LS✱2120~

✱

Required

447

Loop Identifier Code

M 1

1/4

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

This data element must have the value of "2120".

NM1 - DEPENDENT BENEFIT RELATED ENTITY NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when provider was identified in 2100D PRV02 and PRV03 by Identification Number (not Taxonomy Code) in the 270 Inquiry and was used in the determination of the eligibility or benefit response;
OR
Required when needed to identify an entity associated with the eligibility or benefits being identified in the 2110D loop such as a provider (e.g. primary care provider), an individual, an organization, another payer, or another information source;
If not required by this implementation guide, do not send.

TR3 Example:

NM1✱P3✱1✱JONES✱MARCUS✱✱✱MD✱SV✱111223333~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Contracted Service Provider

Preferred Provider Organization (PPO)

Provider

Third-Party Administrator

Employer

Other Physician

Facility

Gateway Provider

Group

Independent Physicians Association (IPA)

Insured or Subscriber

Use if identifying an insured or subscriber to a plan other than the information source (such as in a co-ordination of benefits situation).

Legal Representative

Origin Carrier

Use if identifying an organization that added information relating to other insurance.

Primary Care Provider

Prior Insurance Carrier

Plan Sponsor

Payer

PRP

Primary Payer

SEP

Secondary Payer

TTP

Tertiary Payer

VER

Party Performing Verification

Use this code when identifying the true Information Source and no other code is appropriate. See Section 1.4.7.1 271 item 11 for additional information.

Vendor

Organization Completing Configuration Change

Use if identifying an organization that changed information relating to other insurance.

Utilization Management Organization

Managed Care Organization

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

Use this code to indicate whether the entity is an individual person or an organization.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when needed to identify by name an entity associated with the eligibility or benefits being identified in the 2110D loop such as a provider (e.g. Primary Care Provider), an individual, an organization, another payer, or another information source.ORRequired when NM109 is not used.If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Last or Organization Name

Use this name for the organization name if the entity type qualifier is a non-person entity. Otherwise, this will be the individual's last name.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 is "1" and NM103 is used. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

INDUSTRY NAME: Benefit Related Entity Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

INDUSTRY NAME: Benefit Related Entity Name Suffix

Use for name suffix only (e.g. Sr, Jr, II, III, etc.).

Situational

Identification Code Qualifier

O 1

1/2

Code designating the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when needed to identify by Identification Code an entity associated with the eligibility or benefits being identified in the 2110D loop such as a provider (e.g. Primary Care Provider), an individual, an organization, another payer, or another information source.ORRequired when NM103 is not used.If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

CODE

DEFINITION

Employer's Identification Number

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Electronic Transmitter Identification Number (ETIN)

Facility Identification

Federal Taxpayer's Identification Number

Standard Unique Health Identifier for each Individual in the United States

Member Identification Number

National Association of Insurance Commissioners (NAIC) Identification

Payor Identification

Pharmacy Processor Number

Service Provider Number

Centers for Medicare and Medicaid Services PlanID

CODE SOURCE: 540: Centers for Medicare and Medicaid Services PlanID

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE: 537: Centers for Medicare & Medicaid Services National Provider Identifier

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Benefit Related Entity Identifier

Use this code for the reference number as qualified by the preceding data element (NM108).

Situational

706

Entity Relationship Code

O 1

Code describing entity relationship

COMMENT: NM110 and NM111 further define the type of entity in NM101.

SEGMENT SYNTAX: C1110

INDUSTRY NAME: Benefit Related Entity Relationship Code

CODE

DEFINITION

Parent

Child

Domestic Partner

Spouse

Employee

Other

Unknown

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - DEPENDENT BENEFIT RELATED ENTITY ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to further identify the entity or individual in loop 2120D NM1 and the information is available. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to identify address information for an entity.

TR3 Example:

N3✱201 PARK AVENUE✱SUITE 300~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Benefit Related Entity Address Line

Use this information for the first line of the address information.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line exists and is available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Address Line

Use this information for the second line of the address information.

N4 - DEPENDENT BENEFIT RELATED ENTITY CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to further identify the entity or individual in loop 2120D NM1 and the information is available. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to identify address information for an entity.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Benefit Related Entity City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

O 1

3/15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

INDUSTRY NAME: Benefit Related Entity Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

O 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Situational

309

Location Qualifier

O 1

1/2

Code identifying type of location

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed by CHAMPUS/TRICARE or CHAMPVA to communicate the DOD Health Service Region. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Location Qualifier

Use this element only to communicate the Department of Defense Health Service Region.

CODE SOURCE 206: Government Bill of Lading Office Code

CODE

DEFINITION

Region

Use this code only to communicate the Department of Defense Health Service Region in N406.

Situational

310

Location Identifier

O 1

1/30

Code which identifies a specific location

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when needed by CHAMPUS/TRICARE or CHAMPVA to communicate the DOD Health Service Region. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity DOD Health Service Region

Use this element only to communicate the Department of Defense Health Service Region.
CODE SOURCE DOD1: Military Health Systems Functional Area Manual - Data.

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Benefit Related Entity Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

PER*IC - DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when Contact Information exists and is available. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment when needed to identify a contact name and/or communications number for the entity identified. This segment allows for three contact numbers to be listed. This segment is used when the information source wishes to provide a contact for the entity identified in loop 2120D NM1.

If telephone extension is sent, it should always be in the occurrence of the communications number following the actual phone number. See the example for an illustration.
If this segment is used, at a minimum either PER02 must be used or PER03 and PER04 must be used. It is recommended that at least PER02, PER03 and PER04 are sent if this segment is used.
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.

TR3 Example:

PER✱IC✱BILLING DEPT✱TE✱2128763654✱EX✱2104✱FX✱2128769304~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

1/20

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

Use this code to specify the type of person or group to which the contact number applies.

CODE

DEFINITION

Information Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the name of the individual to contact is not already defined or is different than the name within 2120D NM1 segment and the name is available;ORRequired when PER03 and PER04 are not present.If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Benefit Related Entity Contact Name

Use this name for the individual's name or group's name to use when contacting the individual or organization.

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

Use this code to specify what type of communication number is following.

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Work Phone Number

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Benefit Related Entity Communication Number

The format for US domestic phone numbers is:
AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number
Use this for the communication number or URL as qualified by the preceding data element.

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a second communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

Use this code to specify what type of communication number is following.

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Work Phone Number

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a second communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Communication Number

The format for US domestic phone numbers is:
AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number
Use this for the communication number or URL as qualified by the preceding data element.

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a third communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

Use this code to specify what type of communication number is following.

CODE

DEFINITION

Electronic Data Interchange Access Number

Electronic Mail

Telephone Extension

Facsimile

Telephone

Uniform Resource Locator (URL)

Work Phone Number

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a third communication contact number, e-mail or Web address is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Related Entity Communication Number

The format for US domestic phone numbers is:
AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number
Use this for the communication number or URL as qualified by the preceding data element.

Not Used

443

Contact Inquiry Reference

O 1

1/20

PRV - DEPENDENT BENEFIT RELATED PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop: