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X12 271 Health Care Eligibility Benefit Response (X279A1)
—
Delimiters
- ~ Segment
- * Element
- > Component
- ^ Repetition
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
detail
Information Source Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
AAA
0250
Request Validation
Max use 9
Optional
Information Receiver Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Information Receiver Name Loop
NM1
0300
Information Receiver Name
Max use 1
Required
REF
0400
Information Receiver Additional Identification
Max use 9
Optional
N3
0600
Information Receiver Address
Max use 1
Optional
N4
0700
Information Receiver City, State, ZIP Code
Max use 1
Optional
AAA
0850
Information Receiver Request Validation
Max use 9
Optional
PRV
0900
Information Receiver Provider Information
Max use 1
Optional
Subscriber Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Subscriber Trace Number
Max use 3
Optional
Subscriber Name Loop
NM1
0300
Subscriber Name
Max use 1
Required
REF
0400
Subscriber Additional Identification
Max use 9
Optional
N3
0600
Subscriber Address
Max use 1
Optional
N4
0700
Subscriber City, State, ZIP Code
Max use 1
Optional
AAA
0850
Subscriber Request Validation
Max use 9
Optional
PRV
0900
Provider Information
Max use 1
Optional
DMG
1000
Subscriber Demographic Information
Max use 1
Optional
INS
1100
Subscriber Relationship
Max use 1
Optional
HI
1150
Subscriber Health Care Diagnosis Code
Max use 1
Optional
DTP
1200
Subscriber Date
Max use 9
Optional
MPI
1275
Subscriber Military Personnel Information
Max use 1
Optional
Subscriber Eligibility or Benefit Information Loop
EB
1300
Subscriber Eligibility or Benefit Information
Max use 1
Required
HSD
1350
Health Care Services Delivery
Max use 9
Optional
REF
1400
Subscriber Additional Identification
Max use 9
Optional
DTP
1500
Subscriber Eligibility/Benefit Date
Max use 20
Optional
AAA
1600
Subscriber Request Validation
Max use 9
Optional
MSG
2500
Message Text
Max use 10
Optional
LS
3300
Loop Header
Max use 1
Optional
Subscriber Benefit Related Entity Name Loop
NM1
3400
Subscriber Benefit Related Entity Name
Max use 1
Required
N3
3600
Subscriber Benefit Related Entity Address
Max use 1
Optional
N4
3700
Subscriber Benefit Related Entity City, State, ZIP Code
Max use 1
Optional
PER
3800
Subscriber Benefit Related Entity Contact Information
Max use 3
Optional
PRV
3900
Subscriber Benefit Related Provider Information
Max use 1
Optional
LE
4000
Loop Trailer
Max use 1
Optional
Dependent Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Dependent Trace Number
Max use 3
Optional
Dependent Name Loop
NM1
0300
Dependent Name
Max use 1
Required
REF
0400
Dependent Additional Identification
Max use 9
Optional
N3
0600
Dependent Address
Max use 1
Optional
N4
0700
Dependent City, State, ZIP Code
Max use 1
Optional
AAA
0850
Dependent Request Validation
Max use 9
Optional
PRV
0900
Provider Information
Max use 1
Optional
DMG
1000
Dependent Demographic Information
Max use 1
Optional
INS
1100
Dependent Relationship
Max use 1
Optional
HI
1150
Dependent Health Care Diagnosis Code
Max use 1
Optional
DTP
1200
Dependent Date
Max use 9
Optional
MPI
1275
Dependent Military Personnel Information
Max use 1
Optional
Dependent Eligibility or Benefit Information Loop
EB
1300
Dependent Eligibility or Benefit Information
Max use 1
Required
HSD
1350
Health Care Services Delivery
Max use 9
Optional
REF
1400
Dependent Additional Identification
Max use 9
Optional
DTP
1500
Dependent Eligibility/Benefit Date
Max use 20
Optional
AAA
1600
Dependent Request Validation
Max use 9
Optional
MSG
2500
Message Text
Max use 10
Optional
LS
3300
Loop Header
Max use 1
Optional
Dependent Benefit Related Entity Name Loop
NM1
3400
Dependent Benefit Related Entity Name
Max use 1
Required
N3
3600
Dependent Benefit Related Entity Address
Max use 1
Optional
N4
3700
Dependent Benefit Related Entity City, State, ZIP Code
Max use 1
Optional
PER
3800
Dependent Benefit Related Entity Contact Information
Max use 3
Optional
PRV
3900
Dependent Benefit Related Provider Information
Max use 1
Optional
LE
4000
Loop Trailer
Max use 1
Optional
SE
4100
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA
Interchange Control Header
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Required
Identifier (ID)
—
- 00
- No Security Information Present (No Meaningful Information in I04)
Required
Identifier (ID)
—
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
Required
Identifier (ID)
Min 1Max 1
—
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Required
Identifier (ID)
Min 1Max 1
—
- I
- Information
- P
- Production Data
- T
- Test Data
GS
Functional Group Header
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
- HB
- Eligibility, Coverage or Benefit Information (271)
Required
Identifier (ID)
Min 1Max 2
—
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Heading
ST
0100
Heading > ST
Transaction Set Header
RequiredMax use 1
—
Usage notes
—
Example
BHT
0200
Heading > BHT
Beginning of Hierarchical Transaction
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 0022
- Information Source, Information Receiver, Subscriber, Dependent
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
—
Usage notes
—
Heading end
Detail
2000A Information Source Level Loop
RequiredMax >1
HL
0100
Detail > Information Source Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
AAA
0250
Detail > Information Source Level Loop > AAA
Request Validation
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 04
- Authorized Quantity Exceeded—
- 41
- Authorization/Access Restrictions—
- 42
- Unable to Respond at Current Time—
- 79
- Invalid Participant Identification—
Required
Identifier (ID)
—
Usage notes
—
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- P
- Please Resubmit Original Transaction
- R
- Resubmission Allowed
- S
- Do Not Resubmit; Inquiry Initiated to a Third Party
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
2100A Information Source Name Loop
RequiredMax 1
NM1
0300
Detail > Information Source Level Loop > Information Source Name Loop > NM1
Information Source Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 2B
- Third-Party Administrator
- 36
- Employer
- GP
- Gateway Provider
- P5
- Plan Sponsor
- PR
- Payer
Required
Identifier (ID)
—
Usage notes
—
- 24
- Employer's Identification Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- FI
- Federal Taxpayer's Identification Number
- NI
- National Association of Insurance Commissioners (NAIC) Identification
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
PER
0800
Detail > Information Source Level Loop > Information Source Name Loop > PER
Information Source Contact Information
OptionalMax use 3
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-03) or Information Source Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Information Source Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Information Source Communication Number (PER-08) is present, then the other is required
Optional
Identifier (ID)
—
Usage notes
—
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Optional
Identifier (ID)
—
Usage notes
—
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Optional
Identifier (ID)
—
Usage notes
—
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
AAA
0850
Detail > Information Source Level Loop > Information Source Name Loop > AAA
Request Validation
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 04
- Authorized Quantity Exceeded—
- 41
- Authorization/Access Restrictions—
- 42
- Unable to Respond at Current Time—
- 79
- Invalid Participant Identification—
- 80
- No Response received - Transaction Terminated—
- T4
- Payer Name or Identifier Missing—
Required
Identifier (ID)
—
Usage notes
—
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- P
- Please Resubmit Original Transaction
- R
- Resubmission Allowed
- S
- Do Not Resubmit; Inquiry Initiated to a Third Party
- W
- Please Wait 30 Days and Resubmit
- X
- Please Wait 10 Days and Resubmit
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
2100A Information Source Name Loop end
2000B Information Receiver Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
2100B Information Receiver Name Loop
RequiredMax 1
NM1
0300
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > NM1
Information Receiver Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 1P
- Provider
- 2B
- Third-Party Administrator
- 36
- Employer
- 80
- Hospital
- FA
- Facility
- GP
- Gateway Provider
- P5
- Plan Sponsor
- PR
- Payer
Required
Identifier (ID)
—
Usage notes
—
- 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
REF
0400
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > REF
Information Receiver Additional Identification
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 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
Optional
String (AN)
Min 1Max 80
—
Usage notes
—
N3
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > N3
Information Receiver Address
OptionalMax use 1
—
Usage notes
—
Example
N4
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > N4
Information Receiver City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
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
AAA
0850
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > AAA
Information Receiver Request Validation
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 15
- Required application data missing—
- 41
- Authorization/Access Restrictions
- 43
- Invalid/Missing Provider Identification
- 44
- Invalid/Missing Provider Name
- 45
- Invalid/Missing Provider Specialty
- 46
- Invalid/Missing Provider Phone Number
- 47
- Invalid/Missing Provider State
- 48
- Invalid/Missing Referring Provider Identification Number
- 50
- Provider Ineligible for Inquiries
- 51
- Provider Not on File
- 79
- Invalid Participant Identification—
- 97
- Invalid or Missing Provider Address
- T4
- Payer Name or Identifier Missing—
Required
Identifier (ID)
—
Usage notes
—
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- R
- Resubmission Allowed
- S
- Do Not Resubmit; Inquiry Initiated to a Third Party
- W
- Please Wait 30 Days and Resubmit
- X
- Please Wait 10 Days and Resubmit
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
PRV
0900
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > PRV
Information Receiver Provider Information
OptionalMax use 1
—
Usage notes
—
Example
If either Reference Identification Qualifier (PRV-02) or Information Receiver Provider Taxonomy Code (PRV-03) is present, then the other is required
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
Optional
Identifier (ID)
—
- PXC
- Health Care Provider Taxonomy Code
2100B Information Receiver Name Loop end
2000C Subscriber Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
TRN
0200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > TRN
Subscriber Trace Number
OptionalMax use 3
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 1
- Current Transaction Trace Numbers—
- 2
- Referenced Transaction Trace Numbers—
2100C Subscriber Name Loop
RequiredMax 1
NM1
0300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1
Subscriber Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required
REF
0400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > REF
Subscriber Additional Identification
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 1L
- Group or Policy Number—
- 1W
- Member Identification Number—
- 3H
- Case Number
- 6P
- Group Number
- 18
- Plan Number
- 49
- Family Unit Number—
- CE
- Class of Contract Code—
- CT
- Contract Number—
- EA
- Medical Record Identification Number
- EJ
- Patient Account Number
- F6
- Health Insurance Claim (HIC) Number—
- GH
- Identification Card Serial Number—
- HJ
- Identity Card Number—
- IF
- Issue Number
- IG
- Insurance Policy Number
- N6
- Plan Network Identification Number
- NQ
- Medicaid Recipient Identification Number—
- Q4
- Prior Identifier Number—
- SY
- Social Security Number—
- Y4
- Agency Claim Number—
N3
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > N3
Subscriber Address
OptionalMax use 1
—
Usage notes
—
Example
N4
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > N4
Subscriber City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Subscriber State Code (N4-02) or Subscriber Country Subdivision Code (N4-07) may be present
If Subscriber Country Subdivision Code (N4-07) is present, then Subscriber Country Code (N4-04) is required
AAA
0850
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > AAA
Subscriber Request Validation
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 64
- Invalid/Missing Patient ID
- 67
- Patient Not Found
Required
Identifier (ID)
—
Usage notes
—
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- R
- Resubmission Allowed—
- S
- Do Not Resubmit; Inquiry Initiated to a Third Party
- W
- Please Wait 30 Days and Resubmit
- X
- Please Wait 10 Days and Resubmit
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly—
PRV
0900
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > PRV
Provider Information
OptionalMax use 1
—
Usage notes
—
Example
If either Reference Identification Qualifier (PRV-02) or Provider Identifier (PRV-03) is present, then the other is required
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
Optional
Identifier (ID)
—
- PXC
- Health Care Provider Taxonomy Code
DMG
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG
Subscriber Demographic Information
OptionalMax use 1
—
Usage notes
—
Example
If either Date Time Period Format Qualifier (DMG-01) or Subscriber Birth Date (DMG-02) is present, then the other is required
INS
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS
Subscriber Relationship
OptionalMax use 1
—
Usage notes
—
Example
HI
1150
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > HI
Subscriber Health Care Diagnosis Code
OptionalMax use 1
—
Usage notes
—
Example
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
DTP
1200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DTP
Subscriber Date
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 096
- Discharge
- 102
- Issue
- 152
- Effective Date of Change
- 291
- Plan
- 307
- Eligibility
- 318
- Added—
- 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
Identifier (ID)
—
Usage notes
—
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
MPI
1275
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > MPI
Subscriber Military Personnel Information
OptionalMax use 1
—
Usage notes
—
Example
If either Date Time Period Format Qualifier (MPI-06) or Date Time Period (MPI-07) is present, then the other is required
Required
Identifier (ID)
—
- A
- Partial
- C
- Current
- L
- Latest
- O
- Oldest
- P
- Prior
- S
- Second Most Current
- T
- Third Most Current
Required
Identifier (ID)
—
- AE
- Active Reserve
- AO
- Active Military - Overseas
- AS
- Academy Student
- AT
- Presidential Appointee
- AU
- Active Military - USA
- CC
- Contractor
- DD
- Dishonorably Discharged
- HD
- Honorably Discharged
- IR
- Inactive Reserves
- LX
- Leave of Absence: Military
- PE
- Plan to Enlist
- RE
- Recommissioned
- RM
- Retired Military - Overseas
- RR
- Retired Without Recall
- RU
- Retired Military - USA
Required
Identifier (ID)
—
- A
- Air Force
- B
- Air Force Reserves
- C
- Army
- D
- Army Reserves
- E
- Coast Guard
- F
- Marine Corps
- G
- Marine Corps Reserves
- H
- National Guard
- I
- Navy
- J
- Navy Reserves
- K
- Other
- L
- Peace Corp
- M
- Regular Armed Forces
- N
- Reserves
- O
- U.S. Public Health Service
- Q
- Foreign Military
- R
- American Red Cross
- S
- Department of Defense
- U
- United Services Organization
- W
- Military Sealift Command
Optional
Identifier (ID)
—
- A1
- Admiral
- A2
- Airman
- A3
- Airman First Class
- B1
- Basic Airman
- B2
- Brigadier General
- C1
- Captain
- C2
- Chief Master Sergeant
- C3
- Chief Petty Officer
- C4
- Chief Warrant
- C5
- Colonel
- C6
- Commander
- C7
- Commodore
- C8
- Corporal
- C9
- Corporal Specialist 4
- E1
- Ensign
- F1
- First Lieutenant
- F2
- First Sergeant
- F3
- First Sergeant-Master Sergeant
- F4
- Fleet Admiral
- G1
- General
- G4
- Gunnery Sergeant
- L1
- Lance Corporal
- L2
- Lieutenant
- L3
- Lieutenant Colonel
- L4
- Lieutenant Commander
- L5
- Lieutenant General
- L6
- Lieutenant Junior Grade
- M1
- Major
- M2
- Major General
- M3
- Master Chief Petty Officer
- M4
- Master Gunnery Sergeant Major
- M5
- Master Sergeant
- M6
- Master Sergeant Specialist 8
- P1
- Petty Officer First Class
- P2
- Petty Officer Second Class
- P3
- Petty Officer Third Class
- P4
- Private
- P5
- Private First Class
- R1
- Rear Admiral
- R2
- Recruit
- S1
- Seaman
- S2
- Seaman Apprentice
- S3
- Seaman Recruit
- S4
- Second Lieutenant
- S5
- Senior Chief Petty Officer
- S6
- Senior Master Sergeant
- S7
- Sergeant
- S8
- Sergeant First Class Specialist 7
- S9
- Sergeant Major Specialist 9
- SA
- Sergeant Specialist 5
- SB
- Staff Sergeant
- SC
- Staff Sergeant Specialist 6
- T1
- Technical Sergeant
- V1
- Vice Admiral
- W1
- Warrant Officer
Optional
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
2110C Subscriber Eligibility or Benefit Information Loop
OptionalMax >1
EB
1300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > EB
Subscriber Eligibility or Benefit Information
RequiredMax use 1
—
Usage notes
—
Example
If either Quantity Qualifier (EB-09) or Benefit Quantity (EB-10) is present, then the other is required
Required
Identifier (ID)
—
Usage notes
—
- 1
- Active Coverage
- 6
- Inactive
- A
- Co-Insurance—
- B
- Co-Payment—
- C
- Deductible—
Optional
Identifier (ID)
—
Usage notes
—
- 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
Optional
Identifier (ID)
Max use 99
—
Usage notes
—
- 30
- Health Benefit Plan Coverage—
Optional
Identifier (ID)
—
- 12
- Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13
- Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14
- Medicare Secondary, No-fault Insurance including Auto is Primary
- 15
- Medicare Secondary Worker's Compensation
- 16
- Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 41
- Medicare Secondary Black Lung
- 42
- Medicare Secondary Veteran's Administration
- 43
- Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- 47
- Medicare Secondary, Other Liability Insurance is Primary
- AP
- Auto Insurance Policy
- C1
- Commercial
- CO
- Consolidated Omnibus Budget Reconciliation Act (COBRA)
- CP
- Medicare Conditionally Primary
- D
- Disability
- DB
- Disability Benefits
- EP
- Exclusive Provider Organization
- FF
- Family or Friends
- GP
- Group Policy
- HM
- Health Maintenance Organization (HMO)
- HN
- Health Maintenance Organization (HMO) - Medicare Risk
- HS
- Special Low Income Medicare Beneficiary
- IN
- Indemnity
- IP
- Individual Policy
- LC
- Long Term Care
- LD
- Long Term Policy
- LI
- Life Insurance
- LT
- Litigation
- MA
- Medicare Part A
- MB
- Medicare Part B
- MC
- Medicaid
- MH
- Medigap Part A
- MI
- Medigap Part B
- MP
- Medicare Primary
- OT
- Other—
- PE
- Property Insurance - Personal
- PL
- Personal
- PP
- Personal Payment (Cash - No Insurance)
- PR
- Preferred Provider Organization (PPO)
- PS
- Point of Service (POS)
- QM
- Qualified Medicare Beneficiary
- RP
- Property Insurance - Real
- SP
- Supplemental Policy
- TF
- Tax Equity Fiscal Responsibility Act (TEFRA)
- WC
- Workers Compensation
- WU
- Wrap Up Policy
Optional
Identifier (ID)
—
- 6
- Hour
- 7
- Day
- 13
- 24 Hours
- 21
- Years
- 22
- Service Year
- 23
- Calendar Year
- 24
- Year to Date
- 25
- Contract
- 26
- Episode
- 27
- Visit
- 28
- Outlier
- 29
- Remaining
- 30
- Exceeded
- 31
- Not Exceeded
- 32
- Lifetime
- 33
- Lifetime Remaining
- 34
- Month
- 35
- Week
- 36
- Admission
Optional
Identifier (ID)
—
Usage notes
—
- 8H
- Minimum
- 99
- Quantity Used
- CA
- Covered - Actual
- CE
- Covered - Estimated
- D3
- Number of Co-insurance Days
- DB
- Deductible Blood Units
- DY
- Days
- HS
- Hours
- LA
- Life-time Reserve - Actual
- LE
- Life-time Reserve - Estimated
- M2
- Maximum
- MN
- Month
- P6
- Number of Services or Procedures
- QA
- Quantity Approved
- S7
- Age, High Value—
- S8
- Age, Low Value—
- VS
- Visits
- YY
- Years
Optional
Identifier (ID)
—
Usage notes
—
- N
- No
- U
- Unknown
- Y
- Yes
Optional
Identifier (ID)
—
Usage notes
—
- N
- No
- U
- Unknown
- W
- Not Applicable—
- Y
- Yes
OptionalMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
Usage notes
—
Required
Identifier (ID)
—
Usage notes
—
- 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—
OptionalMax use 1
To identify one or more diagnosis code pointers
Usage notes
—
HSD
1350
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > HSD
Health Care Services Delivery
OptionalMax use 9
—
Usage notes
—
Example
If either Quantity Qualifier (HSD-01) or Benefit Quantity (HSD-02) is present, then the other is required
If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required
Optional
Identifier (ID)
—
- DA
- Days
- MO
- Months
- VS
- Visit
- WK
- Week
- YR
- Years
Optional
Identifier (ID)
—
- 6
- Hour
- 7
- Day
- 21
- Years
- 22
- Service Year
- 23
- Calendar Year
- 24
- Year to Date
- 25
- Contract
- 26
- Episode
- 27
- Visit
- 28
- Outlier
- 29
- Remaining
- 30
- Exceeded
- 31
- Not Exceeded
- 32
- Lifetime
- 33
- Lifetime Remaining
- 34
- Month
- 35
- Week
Optional
Identifier (ID)
—
- 1
- 1st Week of the Month
- 2
- 2nd Week of the Month
- 3
- 3rd Week of the Month
- 4
- 4th Week of the Month
- 5
- 5th Week of the Month
- 6
- 1st & 3rd Weeks of the Month
- 7
- 2nd & 4th Weeks of the Month
- 8
- 1st Working Day of Period
- 9
- Last Working Day of Period
- A
- Monday through Friday
- B
- Monday through Saturday
- C
- Monday through Sunday
- D
- Monday
- E
- Tuesday
- F
- Wednesday
- G
- Thursday
- H
- Friday
- J
- Saturday
- K
- Sunday
- L
- Monday through Thursday
- M
- Immediately
- N
- As Directed
- O
- Daily Mon. through Fri.
- P
- 1/2 Mon. & 1/2 Thurs.
- Q
- 1/2 Tues. & 1/2 Thurs.
- R
- 1/2 Wed. & 1/2 Fri.
- S
- Once Anytime Mon. through Fri.
- SG
- Tuesday through Friday
- SL
- Monday, Tuesday and Thursday
- SP
- Monday, Tuesday and Friday
- SX
- Wednesday and Thursday
- SY
- Monday, Wednesday and Thursday
- SZ
- Tuesday, Thursday and Friday
- T
- 1/2 Tue. & 1/2 Fri.
- U
- 1/2 Mon. & 1/2 Wed.
- V
- 1/3 Mon., 1/3 Wed., 1/3 Fri.
- W
- Whenever Necessary
- X
- 1/2 By Wed., Bal. By Fri.
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Optional
Identifier (ID)
—
- A
- 1st Shift (Normal Working Hours)
- B
- 2nd Shift
- C
- 3rd Shift
- D
- A.M.
- E
- P.M.
- F
- As Directed
- G
- Any Shift
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
REF
1400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > REF
Subscriber Additional Identification
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 1L
- Group or Policy Number—
- 1W
- Member Identification Number
- 6P
- Group Number
- 9F
- Referral Number
- 18
- Plan Number
- 49
- Family Unit Number—
- ALS
- Alternative List ID—
- CLI
- Coverage List ID—
- F6
- Health Insurance Claim (HIC) Number
- FO
- Drug Formulary Number
- G1
- Prior Authorization Number
- IG
- Insurance Policy Number
- M7
- Medical Assistance Category
- N6
- Plan Network Identification Number
- NQ
- Medicaid Recipient Identification Number
DTP
1500
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > DTP
Subscriber Eligibility/Benefit Date
OptionalMax use 20
—
Usage notes
—
Example
AAA
1600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > AAA
Subscriber Request Validation
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 15
- Required application data missing
- 33
- Input Errors—
- 52
- Service Dates Not Within Provider Plan Enrollment
- 53
- Inquired Benefit Inconsistent with Provider Type
- 54
- Inappropriate Product/Service ID Qualifier
- 55
- Inappropriate Product/Service ID
- 56
- Inappropriate Date
- 57
- Invalid/Missing Date(s) of Service
- 60
- Date of Birth Follows Date(s) of Service
- 61
- Date of Death Precedes Date(s) of Service
- 62
- Date of Service Not Within Allowable Inquiry Period
- 63
- Date of Service in Future
- 69
- Inconsistent with Patient's Age
- 70
- Inconsistent with Patient's Gender
- 98
- Experimental Service or Procedure
- AA
- Authorization Number Not Found—
- AE
- Requires Primary Care Physician Authorization
- AF
- Invalid/Missing Diagnosis Code(s)
- AG
- Invalid/Missing Procedure Code(s)—
- AO
- Additional Patient Condition Information Required—
- CI
- Certification Information Does Not Match Patient—
- E8
- Requires Medical Review
- IA
- Invalid Authorization Number Format—
- MA
- Missing Authorization Number—
Required
Identifier (ID)
—
Usage notes
—
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- R
- Resubmission Allowed
- W
- Please Wait 30 Days and Resubmit
- X
- Please Wait 10 Days and Resubmit
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
MSG
2500
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > MSG
Message Text
OptionalMax use 10
—
Usage notes
—
Example
2115C Subscriber Eligibility or Benefit Additional Information Loop
OptionalMax 10
III
2600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Eligibility or Benefit Additional Information Loop > III
Subscriber Eligibility or Benefit Additional Information
RequiredMax use 1
—
Usage notes
—
Example
If either Code List Qualifier Code (III-01) or Industry Code (III-02) is present, then the other is required
If Code Category (III-03) is present, then Injured Body Part Name (III-04) is required
Optional
Identifier (ID)
—
Usage notes
—
- GR
- National Council on Compensation Insurance (NCCI) Nature of Injury Code
- NI
- Nature of Injury Code—
- ZZ
- Mutually Defined—
2115C Subscriber Eligibility or Benefit Additional Information Loop end
LS
3300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > LS
Loop Header
OptionalMax use 1
—
Example
2120C Subscriber Benefit Related Entity Name Loop
OptionalMax 23
NM1
3400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > NM1
Subscriber Benefit Related Entity Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Benefit Related Entity Identifier (NM1-09) is present, then the other is required
Optional
String (AN)
Min 1Max 35
—
Usage notes
—
Optional
Identifier (ID)
—
Usage notes
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Optional
Identifier (ID)
—
- 01
- Parent
- 02
- Child
- 27
- Domestic Partner
- 41
- Spouse
- 48
- Employee
- 65
- Other
- 72
- Unknown
N3
3600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > N3
Subscriber Benefit Related Entity Address
OptionalMax use 1
—
Usage notes
—
Example
N4
3700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > N4
Subscriber Benefit Related Entity City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Benefit Related Entity State Code (N4-02) or Benefit Related Entity Country Subdivision Code (N4-07) may be present
If Benefit Related Entity DOD Health Service Region (N4-06) is present, then Benefit Related Entity Location Qualifier (N4-05) is required
If Benefit Related Entity Country Subdivision Code (N4-07) is present, then Benefit Related Entity Country Code (N4-04) is required
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
PER
3800
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > PER
Subscriber Benefit Related Entity Contact Information
OptionalMax use 3
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-03) or Benefit Related Entity Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Benefit Related Entity Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Benefit Related Entity Communication Number (PER-08) is present, then the other is required
Optional
Identifier (ID)
—
Usage notes
—
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
- WP
- Work Phone Number
Optional
Identifier (ID)
—
Usage notes
—
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
- WP
- Work Phone Number
Optional
Identifier (ID)
—
Usage notes
—
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
- WP
- Work Phone Number
PRV
3900
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > PRV
Subscriber Benefit Related Provider Information
OptionalMax use 1
—
Usage notes
—
Example
If either Reference Identification Qualifier (PRV-02) or Benefit Related Entity Provider Taxonomy Code (PRV-03) is present, then the other is required
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
Optional
Identifier (ID)
—
- PXC
- Health Care Provider Taxonomy Code
2120C Subscriber Benefit Related Entity Name Loop end
LE
4000
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > LE
Loop Trailer
OptionalMax use 1
—
Example
2110C Subscriber Eligibility or Benefit Information Loop end
2100C Subscriber Name Loop end
2000D Dependent Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
TRN
0200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > TRN
Dependent Trace Number
OptionalMax use 3
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 1
- Current Transaction Trace Numbers—
- 2
- Referenced Transaction Trace Numbers—
2100D Dependent Name Loop
RequiredMax 1
NM1
0300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1
Dependent Name
RequiredMax use 1
—
Usage notes
—
Example
REF
0400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > REF
Dependent Additional Identification
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 1L
- Group or Policy Number—
- 1W
- Member Identification Number—
- 6P
- Group Number
- 18
- Plan Number
- 49
- Family Unit Number—
- CE
- Class of Contract Code—
- CT
- Contract Number—
- EA
- Medical Record Identification Number
- EJ
- Patient Account Number
- F6
- Health Insurance Claim (HIC) Number—
- GH
- Identification Card Serial Number—
- HJ
- Identity Card Number—
- IF
- Issue Number
- IG
- Insurance Policy Number
- MRC
- Eligibility Category
- N6
- Plan Network Identification Number
- NQ
- Medicaid Recipient Identification Number—
- Q4
- Prior Identifier Number—
- SY
- Social Security Number—
- Y4
- Agency Claim Number—
N3
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N3
Dependent Address
OptionalMax use 1
—
Usage notes
—
Example
N4
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N4
Dependent City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Dependent State Code (N4-02) or Dependent Country Subdivision Code (N4-07) may be present
If Dependent Country Subdivision Code (N4-07) is present, then Dependent Country Code (N4-04) is required
AAA
0850
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > AAA
Dependent Request Validation
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 15
- Required application data missing
- 35
- Out of Network—
- 42
- Unable to Respond at Current Time—
- 43
- Invalid/Missing Provider Identification
- 45
- Invalid/Missing Provider Specialty
- 47
- Invalid/Missing Provider State
- 48
- Invalid/Missing Referring Provider Identification Number
- 49
- Provider is Not Primary Care Physician
- 51
- Provider Not on File
- 52
- Service Dates Not Within Provider Plan Enrollment
- 56
- Inappropriate Date
- 57
- Invalid/Missing Date(s) of Service
- 58
- Invalid/Missing Date-of-Birth—
- 60
- Date of Birth Follows Date(s) of Service
- 61
- Date of Death Precedes Date(s) of Service
- 62
- Date of Service Not Within Allowable Inquiry Period
- 63
- Date of Service in Future
- 64
- Invalid/Missing Patient ID
- 65
- Invalid/Missing Patient Name—
- 66
- Invalid/Missing Patient Gender Code
- 67
- Patient Not Found—
- 68
- Duplicate Patient ID Number
- 71
- Patient Birth Date Does Not Match That for the Patient on the Database—
- 77
- Subscriber Found, Patient Not Found
Required
Identifier (ID)
—
Usage notes
—
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- R
- Resubmission Allowed—
- S
- Do Not Resubmit; Inquiry Initiated to a Third Party
- W
- Please Wait 30 Days and Resubmit
- X
- Please Wait 10 Days and Resubmit
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly—
PRV
0900
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > PRV
Provider Information
OptionalMax use 1
—
Usage notes
—
Example
If either Reference Identification Qualifier (PRV-02) or Provider Identifier (PRV-03) is present, then the other is required
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
Optional
Identifier (ID)
—
Usage notes
—
- PXC
- Health Care Provider Taxonomy Code
DMG
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG
Dependent Demographic Information
OptionalMax use 1
—
Usage notes
—
Example
If either Date Time Period Format Qualifier (DMG-01) or Dependent Birth Date (DMG-02) is present, then the other is required
INS
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS
Dependent Relationship
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 01
- Spouse
- 19
- Child
- 20
- Employee
- 21
- Unknown—
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
Optional
Identifier (ID)
—
Usage notes
—
- 25
- Change in Identifying Data Elements—
HI
1150
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > HI
Dependent Health Care Diagnosis Code
OptionalMax use 1
—
Usage notes
—
Example
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
DTP
1200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DTP
Dependent Date
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 096
- Discharge
- 102
- Issue
- 152
- Effective Date of Change
- 291
- Plan
- 307
- Eligibility
- 318
- Added—
- 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
Identifier (ID)
—
Usage notes
—
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
MPI
1275
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > MPI
Dependent Military Personnel Information
OptionalMax use 1
—
Usage notes
—
Example
If either Date Time Period Format Qualifier (MPI-06) or Date Time Period (MPI-07) is present, then the other is required
Required
Identifier (ID)
—
- A
- Partial
- C
- Current
- L
- Latest
- O
- Oldest
- P
- Prior
- S
- Second Most Current
- T
- Third Most Current
Required
Identifier (ID)
—
- AE
- Active Reserve
- AO
- Active Military - Overseas
- AS
- Academy Student
- AT
- Presidential Appointee
- AU
- Active Military - USA
- CC
- Contractor
- DD
- Dishonorably Discharged
- HD
- Honorably Discharged
- IR
- Inactive Reserves
- LX
- Leave of Absence: Military
- PE
- Plan to Enlist
- RE
- Recommissioned
- RM
- Retired Military - Overseas
- RR
- Retired Without Recall
- RU
- Retired Military - USA
Required
Identifier (ID)
—
- A
- Air Force
- B
- Air Force Reserves
- C
- Army
- D
- Army Reserves
- E
- Coast Guard
- F
- Marine Corps
- G
- Marine Corps Reserves
- H
- National Guard
- I
- Navy
- J
- Navy Reserves
- K
- Other
- L
- Peace Corp
- M
- Regular Armed Forces
- N
- Reserves
- O
- U.S. Public Health Service
- Q
- Foreign Military
- R
- American Red Cross
- S
- Department of Defense
- U
- United Services Organization
- W
- Military Sealift Command
Optional
Identifier (ID)
—
- A1
- Admiral
- A2
- Airman
- A3
- Airman First Class
- B1
- Basic Airman
- B2
- Brigadier General
- C1
- Captain
- C2
- Chief Master Sergeant
- C3
- Chief Petty Officer
- C4
- Chief Warrant
- C5
- Colonel
- C6
- Commander
- C7
- Commodore
- C8
- Corporal
- C9
- Corporal Specialist 4
- E1
- Ensign
- F1
- First Lieutenant
- F2
- First Sergeant
- F3
- First Sergeant-Master Sergeant
- F4
- Fleet Admiral
- G1
- General
- G4
- Gunnery Sergeant
- L1
- Lance Corporal
- L2
- Lieutenant
- L3
- Lieutenant Colonel
- L4
- Lieutenant Commander
- L5
- Lieutenant General
- L6
- Lieutenant Junior Grade
- M1
- Major
- M2
- Major General
- M3
- Master Chief Petty Officer
- M4
- Master Gunnery Sergeant Major
- M5
- Master Sergeant
- M6
- Master Sergeant Specialist 8
- P1
- Petty Officer First Class
- P2
- Petty Officer Second Class
- P3
- Petty Officer Third Class
- P4
- Private
- P5
- Private First Class
- R1
- Rear Admiral
- R2
- Recruit
- S1
- Seaman
- S2
- Seaman Apprentice
- S3
- Seaman Recruit
- S4
- Second Lieutenant
- S5
- Senior Chief Petty Officer
- S6
- Senior Master Sergeant
- S7
- Sergeant
- S8
- Sergeant First Class Specialist 7
- S9
- Sergeant Major Specialist 9
- SA
- Sergeant Specialist 5
- SB
- Staff Sergeant
- SC
- Staff Sergeant Specialist 6
- T1
- Technical Sergeant
- V1
- Vice Admiral
- W1
- Warrant Officer
Optional
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
2110D Dependent Eligibility or Benefit Information Loop
OptionalMax >1
EB
1300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > EB
Dependent Eligibility or Benefit Information
RequiredMax use 1
—
Usage notes
—
Example
If either Quantity Qualifier (EB-09) or Benefit Quantity (EB-10) is present, then the other is required
Required
Identifier (ID)
—
Usage notes
—
- 1
- Active Coverage
- 2
- Active - Full Risk Capitation
- 3
- Active - Services Capitated
- 4
- Active - Services Capitated to Primary Care Physician
- 5
- Active - Pending Investigation
- 6
- Inactive
- 7
- Inactive - Pending Eligibility Update
- 8
- Inactive - Pending Investigation
- A
- Co-Insurance—
- B
- Co-Payment—
- C
- Deductible—
- CB
- Coverage Basis
- D
- Benefit Description
- E
- Exclusions
- F
- Limitations
- G
- Out of Pocket (Stop Loss)—
- H
- Unlimited
- I
- Non-Covered
- J
- Cost Containment—
- K
- Reserve
- L
- Primary Care Provider
- M
- Pre-existing Condition
- MC
- Managed Care Coordinator
- N
- Services Restricted to Following Provider
- O
- Not Deemed a Medical Necessity
- P
- Benefit Disclaimer—
- Q
- Second Surgical Opinion Required
- R
- Other or Additional Payor
- S
- Prior Year(s) History
- T
- Card(s) Reported Lost/Stolen—
- U
- Contact Following Entity for Eligibility or Benefit Information
- V
- Cannot Process
- W
- Other Source of Data
- X
- Health Care Facility
- Y
- Spend Down—
Optional
Identifier (ID)
—
Usage notes
—
- 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
Optional
Identifier (ID)
Max use 99
—
Usage notes
—
- 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
Optional
Identifier (ID)
—
- 12
- Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13
- Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14
- Medicare Secondary, No-fault Insurance including Auto is Primary
- 15
- Medicare Secondary Worker's Compensation
- 16
- Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 41
- Medicare Secondary Black Lung
- 42
- Medicare Secondary Veteran's Administration
- 43
- Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- 47
- Medicare Secondary, Other Liability Insurance is Primary
- AP
- Auto Insurance Policy
- C1
- Commercial
- CO
- Consolidated Omnibus Budget Reconciliation Act (COBRA)
- CP
- Medicare Conditionally Primary
- D
- Disability
- DB
- Disability Benefits
- EP
- Exclusive Provider Organization
- FF
- Family or Friends
- GP
- Group Policy
- HM
- Health Maintenance Organization (HMO)
- HN
- Health Maintenance Organization (HMO) - Medicare Risk
- HS
- Special Low Income Medicare Beneficiary
- IN
- Indemnity
- IP
- Individual Policy
- LC
- Long Term Care
- LD
- Long Term Policy
- LI
- Life Insurance
- LT
- Litigation
- MA
- Medicare Part A
- MB
- Medicare Part B
- MC
- Medicaid
- MH
- Medigap Part A
- MI
- Medigap Part B
- MP
- Medicare Primary
- OT
- Other—
- PE
- Property Insurance - Personal
- PL
- Personal
- PP
- Personal Payment (Cash - No Insurance)
- PR
- Preferred Provider Organization (PPO)
- PS
- Point of Service (POS)
- QM
- Qualified Medicare Beneficiary
- RP
- Property Insurance - Real
- SP
- Supplemental Policy
- TF
- Tax Equity Fiscal Responsibility Act (TEFRA)
- WC
- Workers Compensation
- WU
- Wrap Up Policy
Optional
Identifier (ID)
—
- 6
- Hour
- 7
- Day
- 13
- 24 Hours
- 21
- Years
- 22
- Service Year
- 23
- Calendar Year
- 24
- Year to Date
- 25
- Contract
- 26
- Episode
- 27
- Visit
- 28
- Outlier
- 29
- Remaining
- 30
- Exceeded
- 31
- Not Exceeded
- 32
- Lifetime
- 33
- Lifetime Remaining
- 34
- Month
- 35
- Week
- 36
- Admission
Optional
Identifier (ID)
—
Usage notes
—
- 8H
- Minimum
- 99
- Quantity Used
- CA
- Covered - Actual
- CE
- Covered - Estimated
- D3
- Number of Co-insurance Days
- DB
- Deductible Blood Units
- DY
- Days
- HS
- Hours
- LA
- Life-time Reserve - Actual
- LE
- Life-time Reserve - Estimated
- M2
- Maximum
- MN
- Month
- P6
- Number of Services or Procedures
- QA
- Quantity Approved
- S7
- Age, High Value—
- S8
- Age, Low Value—
- VS
- Visits
- YY
- Years
Optional
Identifier (ID)
—
Usage notes
—
- N
- No
- U
- Unknown
- Y
- Yes
Optional
Identifier (ID)
—
Usage notes
—
- N
- No
- U
- Unknown
- W
- Not Applicable—
- Y
- Yes
OptionalMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
Usage notes
—
Required
Identifier (ID)
—
Usage notes
—
- 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—
OptionalMax use 1
To identify one or more diagnosis code pointers
Usage notes
—
HSD
1350
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > HSD
Health Care Services Delivery
OptionalMax use 9
—
Usage notes
—
Example
If either Quantity Qualifier (HSD-01) or Benefit Quantity (HSD-02) is present, then the other is required
If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required
Optional
Identifier (ID)
—
- DA
- Days
- MO
- Months
- VS
- Visit
- WK
- Week
- YR
- Years
Optional
Identifier (ID)
—
- 6
- Hour
- 7
- Day
- 21
- Years
- 22
- Service Year
- 23
- Calendar Year
- 24
- Year to Date
- 25
- Contract
- 26
- Episode
- 27
- Visit
- 28
- Outlier
- 29
- Remaining
- 30
- Exceeded
- 31
- Not Exceeded
- 32
- Lifetime
- 33
- Lifetime Remaining
- 34
- Month
- 35
- Week
Optional
Identifier (ID)
—
- 1
- 1st Week of the Month
- 2
- 2nd Week of the Month
- 3
- 3rd Week of the Month
- 4
- 4th Week of the Month
- 5
- 5th Week of the Month
- 6
- 1st & 3rd Weeks of the Month
- 7
- 2nd & 4th Weeks of the Month
- 8
- 1st Working Day of Period
- 9
- Last Working Day of Period
- A
- Monday through Friday
- B
- Monday through Saturday
- C
- Monday through Sunday
- D
- Monday
- E
- Tuesday
- F
- Wednesday
- G
- Thursday
- H
- Friday
- J
- Saturday
- K
- Sunday
- L
- Monday through Thursday
- M
- Immediately
- N
- As Directed
- O
- Daily Mon. through Fri.
- P
- 1/2 Mon. & 1/2 Thurs.
- Q
- 1/2 Tues. & 1/2 Thurs.
- R
- 1/2 Wed. & 1/2 Fri.
- S
- Once Anytime Mon. through Fri.
- SG
- Tuesday through Friday
- SL
- Monday, Tuesday and Thursday
- SP
- Monday, Tuesday and Friday
- SX
- Wednesday and Thursday
- SY
- Monday, Wednesday and Thursday
- SZ
- Tuesday, Thursday and Friday
- T
- 1/2 Tue. & 1/2 Fri.
- U
- 1/2 Mon. & 1/2 Wed.
- V
- 1/3 Mon., 1/3 Wed., 1/3 Fri.
- W
- Whenever Necessary
- X
- 1/2 By Wed., Bal. By Fri.
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Optional
Identifier (ID)
—
- A
- 1st Shift (Normal Working Hours)
- B
- 2nd Shift
- C
- 3rd Shift
- D
- A.M.
- E
- P.M.
- F
- As Directed
- G
- Any Shift
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
REF
1400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > REF
Dependent Additional Identification
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 1L
- Group or Policy Number—
- 1W
- Member Identification Number
- 6P
- Group Number
- 9F
- Referral Number
- 18
- Plan Number
- 49
- Family Unit Number—
- ALS
- Alternative List ID—
- CLI
- Coverage List ID—
- F6
- Health Insurance Claim (HIC) Number
- FO
- Drug Formulary Number
- G1
- Prior Authorization Number
- IG
- Insurance Policy Number
- N6
- Plan Network Identification Number
- NQ
- Medicaid Recipient Identification Number
DTP
1500
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > DTP
Dependent Eligibility/Benefit Date
OptionalMax use 20
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 096
- Discharge
- 193
- Period Start
- 194
- Period End
- 198
- Completion
- 290
- Coordination of Benefits
- 291
- Plan—
- 292
- Benefit
- 295
- Primary Care Provider
- 304
- Latest Visit or Consultation
- 307
- Eligibility
- 318
- Added
- 346
- Plan Begin—
- 348
- Benefit Begin
- 349
- Benefit End
- 356
- Eligibility Begin
- 357
- Eligibility End
- 435
- Admission
- 472
- Service
- 636
- Date of Last Update
- 771
- Status
Required
Identifier (ID)
—
Usage notes
—
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
AAA
1600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > AAA
Dependent Request Validation
OptionalMax use 9
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 15
- Required application data missing
- 33
- Input Errors—
- 52
- Service Dates Not Within Provider Plan Enrollment
- 53
- Inquired Benefit Inconsistent with Provider Type
- 54
- Inappropriate Product/Service ID Qualifier
- 55
- Inappropriate Product/Service ID
- 56
- Inappropriate Date
- 57
- Invalid/Missing Date(s) of Service
- 60
- Date of Birth Follows Date(s) of Service
- 61
- Date of Death Precedes Date(s) of Service
- 62
- Date of Service Not Within Allowable Inquiry Period
- 63
- Date of Service in Future
- 69
- Inconsistent with Patient's Age
- 70
- Inconsistent with Patient's Gender
- 98
- Experimental Service or Procedure
- AA
- Authorization Number Not Found—
- AE
- Requires Primary Care Physician Authorization
- AF
- Invalid/Missing Diagnosis Code(s)
- AG
- Invalid/Missing Procedure Code(s)—
- AO
- Additional Patient Condition Information Required—
- CI
- Certification Information Does Not Match Patient—
- E8
- Requires Medical Review
- IA
- Invalid Authorization Number Format—
- MA
- Missing Authorization Number—
Required
Identifier (ID)
—
Usage notes
—
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- R
- Resubmission Allowed
- W
- Please Wait 30 Days and Resubmit
- X
- Please Wait 10 Days and Resubmit
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
MSG
2500
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > MSG
Message Text
OptionalMax use 10
—
Usage notes
—
Example
2115D Dependent Eligibility or Benefit Additional Information Loop
OptionalMax 10
III
2600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Eligibility or Benefit Additional Information Loop > III
Dependent Eligibility or Benefit Additional Information
RequiredMax use 1
—
Usage notes
—
Example
If either Code List Qualifier Code (III-01) or Industry Code (III-02) is present, then the other is required
If Code Category (III-03) is present, then Injured Body Part Name (III-04) is required
Optional
Identifier (ID)
—
Usage notes
—
- GR
- National Council on Compensation Insurance (NCCI) Nature of Injury Code
- NI
- Nature of Injury Code—
- ZZ
- Mutually Defined—
2115D Dependent Eligibility or Benefit Additional Information Loop end
LS
3300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > LS
Loop Header
OptionalMax use 1
—
Example
2120D Dependent Benefit Related Entity Name Loop
OptionalMax 23
NM1
3400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Benefit Related Entity Name Loop > NM1
Dependent Benefit Related Entity Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Benefit Related Entity Identifier (NM1-09) is present, then the other is required
Required
Identifier (ID)
—
- 1I
- Preferred Provider Organization (PPO)—
- 1P
- Provider
- 2B
- Third-Party Administrator
- 13
- Contracted Service Provider
- 36
- Employer
- 73
- Other Physician
- FA
- Facility
- GP
- Gateway Provider
- GW
- Group
- I3
- Independent Physicians Association (IPA)
- IL
- Insured or Subscriber—
- LR
- Legal Representative
- OC
- Origin Carrier—
- P3
- Primary Care Provider
- P4
- Prior Insurance Carrier
- P5
- Plan Sponsor
- PR
- Payer
- PRP
- Primary Payer
- SEP
- Secondary Payer
- TTP
- Tertiary Payer
- VER
- Party Performing Verification—
- VN
- Vendor
- VY
- Organization Completing Configuration Change—
- X3
- Utilization Management Organization
- Y2
- Managed Care Organization
Optional
String (AN)
Min 1Max 60
—
Usage notes
—
Optional
Identifier (ID)
—
Usage notes
—
- 24
- Employer's Identification Number
- 34
- Social Security Number—
- 46
- Electronic Transmitter Identification Number (ETIN)
- FA
- Facility Identification
- FI
- Federal Taxpayer's Identification Number
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number—
- NI
- National Association of Insurance Commissioners (NAIC) Identification
- 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
Optional
Identifier (ID)
—
- 01
- Parent
- 02
- Child
- 27
- Domestic Partner
- 41
- Spouse
- 48
- Employee
- 65
- Other
- 72
- Unknown
N3
3600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Benefit Related Entity Name Loop > N3
Dependent Benefit Related Entity Address
OptionalMax use 1
—
Usage notes
—
Example
N4
3700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Benefit Related Entity Name Loop > N4
Dependent Benefit Related Entity City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Benefit Related Entity State Code (N4-02) or Benefit Related Entity Country Subdivision Code (N4-07) may be present
If Benefit Related Entity DOD Health Service Region (N4-06) is present, then Benefit Related Entity Location Qualifier (N4-05) is required
If Benefit Related Entity Country Subdivision Code (N4-07) is present, then Benefit Related Entity Country Code (N4-04) is required
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
PER
3800
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Benefit Related Entity Name Loop > PER
Dependent Benefit Related Entity Contact Information
OptionalMax use 3
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-03) or Benefit Related Entity Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Benefit Related Entity Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Benefit Related Entity Communication Number (PER-08) is present, then the other is required
Optional
Identifier (ID)
—
Usage notes
—
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
- WP
- Work Phone Number
Optional
Identifier (ID)
—
Usage notes
—
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
- WP
- Work Phone Number
Optional
Identifier (ID)
—
Usage notes
—
- ED
- Electronic Data Interchange Access Number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
- WP
- Work Phone Number
PRV
3900
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Benefit Related Entity Name Loop > PRV
Dependent Benefit Related Provider Information
OptionalMax use 1
—
Usage notes
—
Example
If either Reference Identification Qualifier (PRV-02) or Benefit Related Entity Provider Taxonomy Code (PRV-03) is present, then the other is required
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
Optional
Identifier (ID)
—
- PXC
- Health Care Provider Taxonomy Code
2120D Dependent Benefit Related Entity Name Loop end
LE
4000
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > LE
Loop Trailer
OptionalMax use 1
—
Example
2110D Dependent Eligibility or Benefit Information Loop end
2100D Dependent Name Loop end
2000D Dependent Level Loop end
2000C Subscriber Level Loop end
2000B Information Receiver Level Loop end
2000A Information Source Level Loop end
SE
4100
Detail > SE
Transaction Set Trailer
RequiredMax use 1
—
Usage notes
—
Example
Detail end
GE
Functional Group Trailer
RequiredMax use 1
—
Example
IEA
Interchange Control Trailer
RequiredMax use 1
—
Example
EDI Samples
Example 1b: Error Response from Payer to Clinic Not Eligible for Inquiries with Payer
ST*271*4323*005010X279A1~
BHT*0022*11*10001234*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
AAA*Y**50*N~
SE*8*4323~
BHT*0022*11*10001234*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
AAA*Y**50*N~
SE*8*4323~
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