X12 270 Health Care Eligibility Benefit Inquiry (X279A1)

X12 Release 5010

Delimiters

• ~ Segment
• * Element
• > Component
• ^ Repetition

ISA Interchange Control Header

Required · Max use 1

ISA-01 · I01 · Authorization Information Qualifier · Required · Identifier (ID)

• 00: No Authorization Information Present (No Meaningful Information in I02)

ISA-02 · I02 · Authorization Information · Required · String (AN) · Min 10 Max 10

ISA-03 · I03 · Security Information Qualifier · Required · Identifier (ID)

• 00: No Security Information Present (No Meaningful Information in I04)

ISA-04 · I04 · Security Information · Required · String (AN) · Min 10 Max 10

ISA-05 · I05 · Interchange ID Qualifier · Required · Identifier (ID)

• ZZ: Mutually Defined

ISA-06 · I06 · Interchange Sender ID · Required · String (AN) · Min 15 Max 15

ISA-07 · I05 · Interchange ID Qualifier · Required · Identifier (ID)

• 01: Duns (Dun & Bradstreet)

ISA-08 · I07 · Interchange Receiver ID · Required · String (AN) · Min 15 Max 15

ISA-09 · I08 · Interchange Date · Required · Date (DT) · YYMMDD format

ISA-10 · I09 · Interchange Time · Required · Time (TM) · HHMM format

ISA-11 · I65 · Repetition Separator · Required · String (AN) · Min 1 Max 1

• ^: Repetition Separator

ISA-12 · I11 · Interchange Control Version Number · Required · Identifier (ID)

• 00501: Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

ISA-13 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

ISA-14 · I13 · Acknowledgment Requested · Required · Identifier (ID) · Min 1 Max 1

• 0: No Interchange Acknowledgment Requested
• 1: Interchange Acknowledgment Requested (TA1)

ISA-15 · I14 · Interchange Usage Indicator · Required · Identifier (ID) · Min 1 Max 1

• I: Information
• P: Production Data
• T: Test Data

ISA-16 · I15 · Component Element Separator · Required · String (AN) · Min 1 Max 1

• >: Component Element Separator

GS Functional Group Header

Required · Max use 1

GS-01 · 479 · Functional Identifier Code · Required · Identifier (ID)

• HS: Eligibility, Coverage or Benefit Inquiry (270)

GS-02 · 142 · Application Sender's Code · Required · String (AN) · Min 2 Max 15

GS-03 · 124 · Application Receiver's Code · Required · String (AN) · Min 2 Max 15

Example values

• BCCA

• DEN

• 030240928

GS-04 · 373 · Date · Required · Date (DT) · CCYYMMDD format

GS-05 · 337 · Time · Required · Time (TM) · HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

GS-06 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

GS-07 · 455 · Responsible Agency Code · Required · Identifier (ID) · Min 1 Max 2

• T: Transportation Data Coordinating Committee (TDCC)
• X: Accredited Standards Committee X12

GS-08 · 480 · Version / Release / Industry Identifier Code · Required · String (AN)

005010X279A1

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

ST-01 · 143 · Transaction Set Identifier Code · Required · Identifier (ID)

• 270: Eligibility, Coverage or Benefit Inquiry

ST-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

ST-03 · 1705 · Implementation Convention Reference · Required · String (AN)

• 005010X279A1: Healthcare Eligibility, Coverage or Benefit

0200 Heading > BHT

BHT Beginning of Hierarchical Transaction

Required · Max use 1

BHT-01 · 1005 · Hierarchical Structure Code · Required · Identifier (ID)

• 0022: Information Source, Information Receiver, Subscriber, Dependent

BHT-02 · 353 · Transaction Set Purpose Code · Required · Identifier (ID)

• 13: Request

BHT-03 · 127 · Submitter Transaction Identifier · Optional · String (AN) · Min 1 Max 50

BHT-04 · 373 · Transaction Set Creation Date · Required · Date (DT) · CCYYMMDD format

BHT-05 · 337 · Transaction Set Creation Time · Required · Time (TM) · HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

BHT-06 · 640 · Transaction Type Code · Optional · Identifier (ID)

• RT: Spend Down

Detail

2000A Information Source Level Loop Required Max >1

0100 Detail > Information Source Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 20: Information Source

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

2100A Information Source Name Loop Required Max 1

0300 Detail > Information Source Level Loop > Information Source Name Loop > NM1

NM1 Information Source Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 2B: Third-Party Administrator
• 36: Employer
• GP: Gateway Provider
• P5: Plan Sponsor
• PR: Payer

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Information Source Last or Organization Name · Required · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Information Source First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Information Source Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Information Source Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• PI: Payor Identification

NM1-09 · 67 · Information Source Primary Identifier · Required · String (AN)

• 040: Anthem Blue Cross

2000B Information Receiver Level Loop Required Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 21: Information Receiver

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

2100B Information Receiver Name Loop Required Max 1

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > NM1

NM1 Information Receiver Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 1P: Provider
• 2B: Third-Party Administrator
• 36: Employer
• 80: Hospital
• FA: Facility
• GP: Gateway Provider
• P5: Plan Sponsor
• PR: Payer

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Information Receiver Last or Organization Name · Required · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Information Receiver First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Information Receiver Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Information Receiver Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• 24: Employer's Identification Number
• 34: Social Security Number
• FI: Federal Taxpayer's Identification Number
• PI: Payor Identification
• PP: Pharmacy Processor Number
• SV: Service Provider Number
• XV: Centers for Medicare and Medicaid Services PlanID
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

NM1-09 · 67 · Information Receiver Identification Number · Required · String (AN) · Min 2 Max 80

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > REF

REF Information Receiver Additional Identification

Optional · Max use 9

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 0B: State License Number
• 1C: Medicare Provider Number
• 1D: Medicaid Provider Number
• 1J: Facility ID Number
• 4A: Personal Identification Number (PIN)
• CT: Contract Number
• EL: Electronic device pin number
• EO: Submitter Identification Number
• HPI: Centers for Medicare and Medicaid Services National Provider Identifier
• JD: User Identification
• N5: Provider Plan Network Identification Number
• N7: Facility Network Identification Number
• Q4: Prior Identifier Number
• SY: Social Security Number
• TJ: Federal Taxpayer's Identification Number

REF-02 · 127 · Information Receiver Additional Identifier · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · Information Receiver Additional Identifier State · Optional · String (AN) · Min 1 Max 80

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > N3

N3 Information Receiver Address

Optional · Max use 1

N3-01 · 166 · Information Receiver Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Information Receiver Additional Address Line · Optional · String (AN) · Min 1 Max 55

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > N4

N4 Information Receiver City, State, ZIP Code

Optional · Max use 1

Only one of Information Receiver State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

N4-01 · 19 · Information Receiver City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Information Receiver State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Information Receiver Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > PRV

PRV Information Receiver Provider Information

Optional · Max use 1

If either Reference Identification Qualifier (PRV-02) or Information Receiver Provider Taxonomy Code (PRV-03) is present, then the other is required

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AD: Admitting
• AT: Attending
• BI: Billing
• CO: Consulting
• CV: Covering
• H: Hospital
• HH: Home Health Care
• LA: Laboratory
• OT: Other Physician
• P1: Pharmacist
• P2: Pharmacy
• PC: Primary Care Physician
• PE: Performing
• R: Rural Health Clinic
• RF: Referring
• SB: Submitting
• SK: Skilled Nursing Facility
• SU: Supervising

PRV-02 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Information Receiver Provider Taxonomy Code · Optional · String (AN) · Min 1 Max 50

2000C Subscriber Level Loop Required Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 22: Subscriber

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 0: No Subordinate HL Segment in This Hierarchical Structure.
• 1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

0200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > TRN

TRN Subscriber Trace Number

Optional · Max use 2

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 1: Current Transaction Trace Numbers

TRN-02 · 127 · Trace Number · Required · String (AN) · Min 1 Max 50

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

2100C Subscriber Name Loop Required Max 1

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

NM1 Subscriber Name

Required · Max use 1

If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• IL: Insured or Subscriber

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Subscriber Last Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Subscriber First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Subscriber Middle Name or Initial · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Subscriber Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• MI: Member Identification Number

NM1-09 · 67 · Subscriber Primary Identifier · Optional · String (AN) · Min 2 Max 80

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > REF

REF Subscriber Additional Identification

Optional · Max use 9

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 6P: Group Number
• SY: Social Security Number

REF-02 · 127 · Subscriber Supplemental Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > N3

N3 Subscriber Address

Optional · Max use 1

N3-01 · 166 · Subscriber Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Subscriber Address Line · Optional · String (AN) · Min 1 Max 55

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > N4

N4 Subscriber City, State, ZIP Code

Optional · Max use 1

Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

N4-01 · 19 · Subscriber City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Subscriber State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Subscriber Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > PRV

PRV Provider Information

Optional · Max use 1

If either Reference Identification Qualifier (PRV-02) or Provider Identifier (PRV-03) is present, then the other is required

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AD: Admitting
• AT: Attending
• BI: Billing
• CO: Consulting
• CV: Covering
• H: Hospital
• HH: Home Health Care
• LA: Laboratory
• OT: Other Physician
• P1: Pharmacist
• P2: Pharmacy
• PC: Primary Care Physician
• PE: Performing
• R: Rural Health Clinic
• RF: Referring
• SK: Skilled Nursing Facility
• SU: Supervising

PRV-02 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• 9K: Servicer
• D3: National Council for Prescription Drug Programs Pharmacy Number
• EI: Employer's Identification Number
• HPI: Centers for Medicare and Medicaid Services National Provider Identifier
• PXC: Health Care Provider Taxonomy Code
• SY: Social Security Number
• TJ: Federal Taxpayer's Identification Number

PRV-03 · 127 · Provider Identifier · Optional · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG

DMG Subscriber Demographic Information

Optional · Max use 1

If either Date Time Period Format Qualifier (DMG-01) or Subscriber Birth Date (DMG-02) is present, then the other is required

DMG-01 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Subscriber Birth Date · Optional · String (AN) · Min 1 Max 35

DMG-03 · 1068 · Subscriber Gender Code · Optional · Identifier (ID)

• F: Female
• M: Male

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

INS Multiple Birth Sequence Number

Optional · Max use 1

INS-01 · 1073 · Insured Indicator · Required · Identifier (ID)

• Y: Yes

INS-02 · 1069 · Individual Relationship Code · Required · Identifier (ID)

• 18: Self

INS-17 · 1470 · Birth Sequence Number · Required · Numeric (N0) · Min 1 Max 9

1150 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > HI

HI Subscriber Health Care Diagnosis Code

Optional · Max use 1

HI-01 · C022 · Health Care Code Information · Required Max use 1 · To send health care codes and their associated dates, amounts and quantities

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABK: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
• BK: International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-02 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-03 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-04 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-05 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-06 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-07 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-08 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

1200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DTP

DTP Subscriber Date

Optional · Max use 2

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 291: Plan

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD
• RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

DTP-03 · 1251 · Date Time Period · Required · String (AN) · Min 1 Max 35

2110C Subscriber Eligibility or Benefit Inquiry Loop Optional Max 99

1300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > EQ

EQ Subscriber Eligibility or Benefit Inquiry

Required · Max use 1

At least one of Service Type Code (EQ-01) or Composite Medical Procedure Identifier (EQ-02) is required

EQ-01 · 1365 · Service Type Code · Optional · Identifier (ID) · Max use 99

• 1: Medical Care
• 2: Surgical
• 4: Diagnostic X-Ray
• 5: Diagnostic Lab
• 6: Radiation Therapy
• 7: Anesthesia
• 8: Surgical Assistance
• 12: Durable Medical Equipment Purchase
• 13: Ambulatory Service Center Facility
• 18: Durable Medical Equipment Rental
• 20: Second Surgical Opinion
• 30: Health Benefit Plan Coverage
• 33: Chiropractic
• 35: Dental Care
• 40: Oral Surgery
• 42: Home Health Care
• 45: Hospice
• 47: Hospital
• 48: Hospital - Inpatient
• 50: Hospital - Outpatient
• 51: Hospital - Emergency Accident
• 52: Hospital - Emergency Medical
• 53: Hospital - Ambulatory Surgical
• 60: General Benefits
• 61: In-vitro Fertilization
• 62: MRI/CAT Scan
• 65: Newborn Care
• 68: Well Baby Care
• 69: Maternity
• 73: Diagnostic Medical
• 76: Dialysis
• 78: Chemotherapy
• 80: Immunizations
• 81: Routine Physical
• 82: Family Planning
• 83: Infertility
• 84: Abortion
• 86: Emergency Services
• 88: Pharmacy
• 93: Podiatry
• 98: Professional (Physician) Visit - Office
• 99: Professional (Physician) Visit - Inpatient
• A0: Professional (Physician) Visit - Outpatient
• A3: Professional (Physician) Visit - Home
• AG: Skilled Nursing Care
• AI: Substance Abuse
• AL: Vision (Optometry)
• BG: Cardiac Rehabilitation
• BH: Pediatric
• BT: Gynecological
• BU: Obstetrical
• BV: Obstetrical/Gynecological
• BY: Physician Visit - Office: Sick
• BZ: Physician Visit - Office: Well
• CE: Mental Health Provider - Inpatient
• CF: Mental Health Provider - Outpatient
• CG: Mental Health Facility - Inpatient
• CH: Mental Health Facility - Outpatient
• CI: Substance Abuse Facility - Inpatient
• CJ: Substance Abuse Facility - Outpatient
• CK: Screening X-ray
• CL: Screening laboratory
• CM: Mammogram, High Risk Patient
• CN: Mammogram, Low Risk Patient
• CO: Flu Vaccination
• DM: Durable Medical Equipment
• MH: Mental Health
• UC: Urgent Care

EQ-02 · C003 · Composite Medical Procedure Identifier · Optional Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers · Usage notes

C003-01 · 235 · Product or Service ID Qualifier · Required · Identifier (ID)

• AD: American Dental Association Codes
• CJ: Current Procedural Terminology (CPT) Codes
• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
• IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
• N4: National Drug Code in 5-4-2 Format
• ZZ: Mutually Defined

C003-02 · 234 · Procedure Code · Required · String (AN) · Min 1 Max 48

C003-03 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-04 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-05 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-06 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

EQ-03 · 1207 · Coverage Level Code · Optional · Identifier (ID)

• FAM: Family

EQ-05 · C004 · Composite Diagnosis Code Pointer · Optional Max use 1 · To identify one or more diagnosis code pointers · Usage notes

C004-01 · 1328 · Diagnosis Code Pointer · Required · Numeric (N0) · Min 1 Max 2

C004-02 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

C004-03 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

C004-04 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

1350 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > AMT

AMT Subscriber Spend Down Amount

Optional · Max use 1

Variants (all may be used)

AMTSubscriber Spend Down Total Billed Amount

AMT-01 · 522 · Amount Qualifier Code · Required · Identifier (ID)

• R: Spend Down

AMT-02 · 782 · Spend Down Amount · Required · Decimal number (R) · Min 1 Max 15

1350 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > AMT

AMT Subscriber Spend Down Total Billed Amount

Optional · Max use 1

Variants (all may be used)

AMTSubscriber Spend Down Amount

AMT-01 · 522 · Amount Qualifier Code · Required · Identifier (ID)

• PB: Billed Amount

AMT-02 · 782 · Spend Down Total Billed Amount · Required · Decimal number (R) · Min 1 Max 15

1700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > III

III Subscriber Eligibility or Benefit Additional Inquiry Information

Optional · Max use 1

III-01 · 1270 · Code List Qualifier Code · Required · Identifier (ID)

• ZZ: Mutually Defined

III-02 · 1271 · Industry Code · Required · String (AN) · Min 1 Max 30

1900 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > REF

REF Subscriber Additional Information

Optional · Max use 1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 9F: Referral Number
• G1: Prior Authorization Number

REF-02 · 127 · Prior Authorization or Referral Number · Required · String (AN) · Min 1 Max 50

2000 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > DTP

DTP Subscriber Eligibility/Benefit Date

Optional · Max use 1

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 291: Plan

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD
• RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

DTP-03 · 1251 · Date Time Period · Required · String (AN) · Min 1 Max 35

2000D Dependent Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 23: Dependent

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 0: No Subordinate HL Segment in This Hierarchical Structure.

0200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > TRN

TRN Dependent Trace Number

Optional · Max use 2

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 1: Current Transaction Trace Numbers

TRN-02 · 127 · Trace Number · Required · String (AN) · Min 1 Max 50

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

2100D Dependent Name Loop Required Max 1

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

NM1 Dependent Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 03: Dependent

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person

NM1-03 · 1035 · Dependent Last Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Dependent First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Dependent Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Dependent Name Suffix · Optional · String (AN) · Min 1 Max 10

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > REF

REF Dependent Additional Identification

Optional · Max use 9

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 6P: Group Number
• SY: Social Security Number

REF-02 · 127 · Dependent Supplemental Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N3

N3 Dependent Address

Optional · Max use 1

N3-01 · 166 · Dependent Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Dependent Address Line · Optional · String (AN) · Min 1 Max 55

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N4

N4 Dependent City, State, ZIP Code

Optional · Max use 1

Only one of Dependent State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

N4-01 · 19 · Dependent City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Dependent State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Dependent Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > PRV

PRV Provider Information

Optional · Max use 1

If either Reference Identification Qualifier (PRV-02) or Provider Identifier (PRV-03) is present, then the other is required

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AD: Admitting
• AT: Attending
• BI: Billing
• CO: Consulting
• CV: Covering
• H: Hospital
• HH: Home Health Care
• LA: Laboratory
• OT: Other Physician
• P1: Pharmacist
• P2: Pharmacy
• PC: Primary Care Physician
• PE: Performing
• R: Rural Health Clinic
• RF: Referring
• SK: Skilled Nursing Facility
• SU: Supervising

PRV-02 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• 9K: Servicer
• D3: National Council for Prescription Drug Programs Pharmacy Number
• EI: Employer's Identification Number
• HPI: Centers for Medicare and Medicaid Services National Provider Identifier
• PXC: Health Care Provider Taxonomy Code
• SY: Social Security Number
• TJ: Federal Taxpayer's Identification Number

PRV-03 · 127 · Provider Identifier · Optional · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG

DMG Dependent Demographic Information

Optional · Max use 1

If either Date Time Period Format Qualifier (DMG-01) or Dependent Birth Date (DMG-02) is present, then the other is required

DMG-01 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Dependent Birth Date · Optional · String (AN) · Min 1 Max 35

DMG-03 · 1068 · Dependent Gender Code · Optional · Identifier (ID)

• F: Female
• M: Male

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS

INS Dependent Relationship

Optional · Max use 1

INS-01 · 1073 · Insured Indicator · Required · Identifier (ID)

• N: No

INS-02 · 1069 · Individual Relationship Code · Required · Identifier (ID)

• 01: Spouse
• 19: Child
• 34: Other Adult

INS-17 · 1470 · Birth Sequence Number · Optional · Numeric (N0) · Min 1 Max 9

1150 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > HI

HI Dependent Health Care Diagnosis Code

Optional · Max use 1

HI-01 · C022 · Health Care Code Information · Required Max use 1 · To send health care codes and their associated dates, amounts and quantities

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABK: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
• BK: International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-02 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-03 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-04 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-05 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-06 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-07 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-08 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

1200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DTP

DTP Dependent Date

Optional · Max use 2

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 291: Plan

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD
• RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

DTP-03 · 1251 · Date Time Period · Required · String (AN) · Min 1 Max 35

2110D Dependent Eligibility or Benefit Inquiry Loop Required Max 99

1300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Inquiry Loop > EQ

EQ Dependent Eligibility or Benefit Inquiry

Required · Max use 1

At least one of Service Type Code (EQ-01) or Composite Medical Procedure Identifier (EQ-02) is required

EQ-01 · 1365 · Service Type Code · Optional · Identifier (ID) · Max use 99

• 1: Medical Care
• 2: Surgical
• 3: Consultation
• 4: Diagnostic X-Ray
• 5: Diagnostic Lab
• 6: Radiation Therapy
• 7: Anesthesia
• 8: Surgical Assistance
• 9: Other Medical
• 10: Blood Charges
• 11: Used Durable Medical Equipment
• 12: Durable Medical Equipment Purchase
• 13: Ambulatory Service Center Facility
• 14: Renal Supplies in the Home
• 15: Alternate Method Dialysis
• 16: Chronic Renal Disease (CRD) Equipment
• 17: Pre-Admission Testing
• 18: Durable Medical Equipment Rental
• 19: Pneumonia Vaccine
• 20: Second Surgical Opinion
• 21: Third Surgical Opinion
• 22: Social Work
• 23: Diagnostic Dental
• 24: Periodontics
• 25: Restorative
• 26: Endodontics
• 27: Maxillofacial Prosthetics
• 28: Adjunctive Dental Services
• 30: Health Benefit Plan Coverage
• 32: Plan Waiting Period
• 33: Chiropractic
• 34: Chiropractic Office Visits
• 35: Dental Care
• 36: Dental Crowns
• 37: Dental Accident
• 38: Orthodontics
• 39: Prosthodontics
• 40: Oral Surgery
• 41: Routine (Preventive) Dental
• 42: Home Health Care
• 43: Home Health Prescriptions
• 44: Home Health Visits
• 45: Hospice
• 46: Respite Care
• 47: Hospital
• 48: Hospital - Inpatient
• 49: Hospital - Room and Board
• 50: Hospital - Outpatient
• 51: Hospital - Emergency Accident
• 52: Hospital - Emergency Medical
• 53: Hospital - Ambulatory Surgical
• 54: Long Term Care
• 55: Major Medical
• 56: Medically Related Transportation
• 57: Air Transportation
• 58: Cabulance
• 59: Licensed Ambulance
• 60: General Benefits
• 61: In-vitro Fertilization
• 62: MRI/CAT Scan
• 63: Donor Procedures
• 64: Acupuncture
• 65: Newborn Care
• 66: Pathology
• 67: Smoking Cessation
• 68: Well Baby Care
• 69: Maternity
• 70: Transplants
• 71: Audiology Exam
• 72: Inhalation Therapy
• 73: Diagnostic Medical
• 74: Private Duty Nursing
• 75: Prosthetic Device
• 76: Dialysis
• 77: Otological Exam
• 78: Chemotherapy
• 79: Allergy Testing
• 80: Immunizations
• 81: Routine Physical
• 82: Family Planning
• 83: Infertility
• 84: Abortion
• 85: AIDS
• 86: Emergency Services
• 87: Cancer
• 88: Pharmacy
• 89: Free Standing Prescription Drug
• 90: Mail Order Prescription Drug
• 91: Brand Name Prescription Drug
• 92: Generic Prescription Drug
• 93: Podiatry
• 94: Podiatry - Office Visits
• 95: Podiatry - Nursing Home Visits
• 96: Professional (Physician)
• 97: Anesthesiologist
• 98: Professional (Physician) Visit - Office
• 99: Professional (Physician) Visit - Inpatient
• A0: Professional (Physician) Visit - Outpatient
• A1: Professional (Physician) Visit - Nursing Home
• A2: Professional (Physician) Visit - Skilled Nursing Facility
• A3: Professional (Physician) Visit - Home
• A4: Psychiatric
• A5: Psychiatric - Room and Board
• A6: Psychotherapy
• A7: Psychiatric - Inpatient
• A8: Psychiatric - Outpatient
• A9: Rehabilitation
• AA: Rehabilitation - Room and Board
• AB: Rehabilitation - Inpatient
• AC: Rehabilitation - Outpatient
• AD: Occupational Therapy
• AE: Physical Medicine
• AF: Speech Therapy
• AG: Skilled Nursing Care
• AH: Skilled Nursing Care - Room and Board
• AI: Substance Abuse
• AJ: Alcoholism
• AK: Drug Addiction
• AL: Vision (Optometry)
• AM: Frames
• AN: Routine Exam
• AO: Lenses
• AQ: Nonmedically Necessary Physical
• AR: Experimental Drug Therapy
• B1: Burn Care
• B2: Brand Name Prescription Drug - Formulary
• B3: Brand Name Prescription Drug - Non-Formulary
• BA: Independent Medical Evaluation
• BB: Partial Hospitalization (Psychiatric)
• BC: Day Care (Psychiatric)
• BD: Cognitive Therapy
• BE: Massage Therapy
• BF: Pulmonary Rehabilitation
• BG: Cardiac Rehabilitation
• BH: Pediatric
• BI: Nursery
• BJ: Skin
• BK: Orthopedic
• BL: Cardiac
• BM: Lymphatic
• BN: Gastrointestinal
• BP: Endocrine
• BQ: Neurology
• BR: Eye
• BS: Invasive Procedures
• BT: Gynecological
• BU: Obstetrical
• BV: Obstetrical/Gynecological
• BW: Mail Order Prescription Drug: Brand Name
• BX: Mail Order Prescription Drug: Generic
• BY: Physician Visit - Office: Sick
• BZ: Physician Visit - Office: Well
• C1: Coronary Care
• CA: Private Duty Nursing - Inpatient
• CB: Private Duty Nursing - Home
• CC: Surgical Benefits - Professional (Physician)
• CD: Surgical Benefits - Facility
• CE: Mental Health Provider - Inpatient
• CF: Mental Health Provider - Outpatient
• CG: Mental Health Facility - Inpatient
• CH: Mental Health Facility - Outpatient
• CI: Substance Abuse Facility - Inpatient
• CJ: Substance Abuse Facility - Outpatient
• CK: Screening X-ray
• CL: Screening laboratory
• CM: Mammogram, High Risk Patient
• CN: Mammogram, Low Risk Patient
• CO: Flu Vaccination
• CP: Eyewear and Eyewear Accessories
• CQ: Case Management
• DG: Dermatology
• DM: Durable Medical Equipment
• DS: Diabetic Supplies
• GF: Generic Prescription Drug - Formulary
• GN: Generic Prescription Drug - Non-Formulary
• GY: Allergy
• IC: Intensive Care
• MH: Mental Health
• NI: Neonatal Intensive Care
• ON: Oncology
• PT: Physical Therapy
• PU: Pulmonary
• RN: Renal
• RT: Residential Psychiatric Treatment
• TC: Transitional Care
• TN: Transitional Nursery Care
• UC: Urgent Care

EQ-02 · C003 · Composite Medical Procedure Identifier · Optional Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers · Usage notes

C003-01 · 235 · Product or Service ID Qualifier · Required · Identifier (ID)

• AD: American Dental Association Codes
• CJ: Current Procedural Terminology (CPT) Codes
• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
• IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
• N4: National Drug Code in 5-4-2 Format
• ZZ: Mutually Defined

C003-02 · 234 · Procedure Code · Required · String (AN) · Min 1 Max 48

C003-03 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-04 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-05 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-06 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

EQ-05 · C004 · Composite Diagnosis Code Pointer · Optional Max use 1 · To identify one or more diagnosis code pointers · Usage notes

C004-01 · 1328 · Diagnosis Code Pointer · Required · Numeric (N0) · Min 1 Max 2

C004-02 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

C004-03 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

C004-04 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

1700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Inquiry Loop > III

III Dependent Eligibility or Benefit Additional Inquiry Information

Optional · Max use 1

III-01 · 1270 · Code List Qualifier Code · Required · Identifier (ID)

• ZZ: Mutually Defined

III-02 · 1271 · Industry Code · Required · String (AN) · Min 1 Max 30

1900 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Inquiry Loop > REF

REF Dependent Additional Information

Optional · Max use 1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 9F: Referral Number
• G1: Prior Authorization Number

REF-02 · 127 · Prior Authorization or Referral Number · Required · String (AN) · Min 1 Max 50

2000 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Inquiry Loop > DTP

DTP Dependent Eligibility/Benefit Date

Optional · Max use 1

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 291: Plan

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD
• RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

DTP-03 · 1251 · Date Time Period · Required · String (AN) · Min 1 Max 35

2100 Detail > SE

SE Transaction Set Trailer

Required · Max use 1

SE-01 · 96 · Transaction Segment Count · Required · Numeric (N0) · Min 1 Max 10

SE-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

GE Functional Group Trailer

Required · Max use 1

GE-01 · 97 · Number of Transaction Sets Included · Required · Numeric (N0) · Min 1 Max 6

GE-02 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

IEA Interchange Control Trailer

Required · Max use 1

IEA-01 · I16 · Number of Included Functional Groups · Required · Numeric (N0) · Min 1 Max 5

IEA-02 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

EDI Samples

Example 1: Generic Request By a Clinic for the Patient’s (Subscriber) Eligibility

ST*270*1234*005010X279A1~
BHT*0022*13*10001234*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*040~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
HL*3*2*22*0~
TRN*1*93175-012547*9877281234~
NM1*IL*1*SMITH*ROBERT****MI*11122333301~
DMG*D8*19430519~
DTP*291*D8*20060501~
EQ*30~
SE*13*1234~

Example 2: Generic Request by a Physician for the Patient’s (Dependent) Eligibility

ST*270*1235*005010X279A1~
BHT*0022*13*10001235*20060501*1320~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*040~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS****SV*0202034~
HL*3*2*22*1~
NM1*IL*1******MI*11122333301~
HL*4*3*23*0~
TRN*1*93175-012547*9877281234~
NM1*03*1*SMITH*MARY~
DMG*D8*19781014~
DTP*291*D8*20060501~
EQ*30~
SE*15*1235~