EDI 270 Health Care Eligibility/Benefit Inquiry

Functional Group HS

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Eligibility/Benefit Inquiry Transaction Set (270) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to inquire about the health care eligibility and benefits associated with a subscriber or a dependent under the subscriber's policy. A subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A dependent is a person who is affiliated with the subscriber such as spouse, child, etc., and therefore may be entitled to benefits.

Heading

1. 010 · ST · Transaction Set Header · Max 1 · Mandatory

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

2. 020 · BGN · Beginning Segment · Max 1 · Optional

   To indicate the beginning of a transaction set.

Detail

1. HL Loop Mandatory Repeat >1

   1. 010 · HL · Hierarchical Level · Max 1 · Mandatory

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

      Valid codes for HL03 to define levels are 20, 21, 22, and 23.

   2. 020 · TRN · Trace · Max 9 · Optional

      To uniquely identify a transaction to an application.

      If the Health Care Eligibility/Benefit Inquiry Transaction Set (270) includes a TRN segment, then the Health Care Eligibility/Benefit Information Transaction Set (271) must return the trace number identified in the TRN segment.

   3. NM1 Loop Mandatory Repeat >1

      1. 030 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

      2. 040 · REF · Reference Numbers · Max 9 · Optional

         To specify identifying numbers.

      3. 050 · N2 · Additional Name Information · Max 1 · Optional

         To specify additional names or those longer than 35 characters in length

      4. 060 · N3 · Address Information · Max 1 · Optional

         To specify the location of the named party

      5. 070 · N4 · Geographic Location · Max 1 · Optional

         To specify the geographic place of the named party

      6. 080 · PER · Administrative Communications Contact · Max 3 · Optional

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

      7. 090 · PRV · Provider Information · Max 1 · Optional

         To specify the identifying characteristics of a provider

         The PRV segment may only appear at the Eligibility or Benefit Information Receiver level (HL03 = 21).

      8. 100 · DMG · Demographic Information · Max 1 · Optional

         To supply demographic information

         The DMG segment may only appear at the Subscriber (HL03 = 22) and Dependent (HL03 = 23) levels.

      9. 110 · INS · Insured Benefit · Max 1 · Optional

         To provide benefit information on insured entities

         The INS segment may only appear at the Subscriber (HL03 = 22) and Dependent (HL03 = 23) levels.

      10. 120 · DTP · Date or Time or Period · Max 9 · Optional

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

      11. EQ Loop Optional Repeat 99

          1. 130 · EQ · Eligibility or Benefit Inquiry · Max 1 · Mandatory

             To specify inquired eligibility or benefit information

             The EQ loop may only appear at the Subscriber (HL03 = 22) and Dependent (HL03 = 23) levels. There must be at least one occurrence of the EQ loop at each iteration of either the Subscriber (HL03 = 22) or Dependent (HL03 = 23) level or both.

          2. 140 · REF · Reference Numbers · Max 1 · Optional

             To specify identifying numbers.

          3. 150 · DTP · Date or Time or Period · Max 9 · Optional

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

2. 160 · SE · Transaction Set Trailer · Max 1 · Mandatory

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