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X12 270 Health Care Eligibility Benefit Inquiry (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
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
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 2
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
PRV
0900
Provider Information
Max use 1
Optional
DMG
1000
Subscriber Demographic Information
Max use 1
Optional
INS
1100
Multiple Birth Sequence Number
Max use 1
Optional
HI
1150
Subscriber Health Care Diagnosis Code
Max use 1
Optional
DTP
1200
Subscriber Date
Max use 2
Optional
Subscriber Eligibility or Benefit Inquiry Loop
EQ
1300
Subscriber Eligibility or Benefit Inquiry
Max use 1
Required
AMT
1350
Subscriber Spend Down Amount
Max use 1
Optional
AMT
1350
Subscriber Spend Down Total Billed Amount
Max use 1
Optional
III
1700
Subscriber Eligibility or Benefit Additional Inquiry Information
Max use 1
Optional
REF
1900
Subscriber Additional Information
Max use 1
Optional
DTP
2000
Subscriber Eligibility/Benefit Date
Max use 1
Optional
Dependent Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Dependent Trace Number
Max use 2
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
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 2
Optional
SE
2100
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)
—
- HS
- Eligibility, Coverage or Benefit Inquiry (270)
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
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
2100A Information Source Name Loop end
2000B Information Receiver Level Loop
RequiredMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 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
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
RequiredMax >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 2
—
Usage notes
—
Example
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
Optional
Identifier (ID)
—
Usage notes
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number—
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
- 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—
- IG
- Insurance Policy Number
- N6
- Plan Network Identification Number
- NQ
- Medicaid Recipient Identification 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 Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
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)
—
Usage notes
—
- 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
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
Multiple Birth Sequence Number
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 2
—
Usage notes
—
Example
2110C Subscriber Eligibility or Benefit Inquiry Loop
OptionalMax 10
EQ
1300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > EQ
Subscriber Eligibility or Benefit Inquiry
RequiredMax use 1
—
Usage notes
—
Example
At least one of Service Type Code (EQ-01) or Composite Medical Procedure Identifier (EQ-02) is required
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
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
—
AMT
1350
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > AMT
Subscriber Spend Down Amount
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTSubscriber Spend Down Total Billed AmountAMT
1350
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > AMT
Subscriber Spend Down Total Billed Amount
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTSubscriber Spend Down AmountIII
1700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > III
Subscriber Eligibility or Benefit Additional Inquiry Information
OptionalMax use 1
—
Usage notes
—
Example
REF
1900
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > REF
Subscriber Additional Information
OptionalMax use 1
—
Usage notes
—
Example
DTP
2000
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > DTP
Subscriber Eligibility/Benefit Date
OptionalMax use 1
—
Usage notes
—
Example
2110C Subscriber Eligibility or Benefit Inquiry 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 2
—
Usage notes
—
Example
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
- 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
- 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 Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
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
—
- 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
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
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 2
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
2110D Dependent Eligibility or Benefit Inquiry Loop
RequiredMax 10
EQ
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
Dependent Eligibility or Benefit Inquiry
RequiredMax use 1
—
Usage notes
—
Example
At least one of Service Type Code (EQ-01) or Composite Medical Procedure Identifier (EQ-02) is required
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
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
—
III
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
Dependent Eligibility or Benefit Additional Inquiry Information
OptionalMax use 1
—
Usage notes
—
Example
REF
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
Dependent Additional Information
OptionalMax use 1
—
Usage notes
—
Example
DTP
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
Dependent Eligibility/Benefit Date
OptionalMax use 1
—
Usage notes
—
Example
2110D Dependent Eligibility or Benefit Inquiry 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
2100
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 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*842610001~
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~
BHT*0022*13*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~
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*842610001~
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~
BHT*0022*13*10001235*20060501*1320~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*842610001~
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~
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