EDI 271 Health Care Eligibility/Benefit Information

Functional Group HB

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Eligibility/Benefit Information Transaction Set (271) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to communicate from health care information sources (i.e. - insurers, sponsors, payors) to health care information receivers (i.e. - physicians, hospitals, medical facilities) information about or changes to health care eligibility or benefits. This information includes but is not limited to: benefit status, explanation of benefit status, dependent coverage level, dates of coverage, covered days and/or non-covered days, amounts for co-insurance, co-pays, deductibles, exclusions and limitations.

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.
      The HL segment is the only mandatory segment within the HL loop, and by itself, the HL segment has no meaning.

   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. 025 · AAA · Request Validation · Max 9 · Optional

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

   4. NM1 Loop Optional 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. 085 · AAA · Request Validation · Max 9 · Optional

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

      8. 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).

      9. 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.

      10. 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.

      11. 120 · DTP · Date or Time or Period · Max 9 · Optional

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

      12. EB Loop Optional Repeat >1

          1. 130 · EB · Eligibility or Benefit Information · Max 1 · Mandatory

             To supply eligibility or benefit information

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

          2. 140 · REF · Reference Numbers · Max 9 · Optional

             To specify identifying numbers.

          3. 150 · DTP · Date or Time or Period · Max 20 · Optional

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

          4. 160 · AAA · Request Validation · Max 9 · Optional

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

          5. 170 · MSG · Message Text · Max 10 · Optional

             To provide a free form format that would allow the transmission of text information.

          6. 175 · LS · Loop Header · Max 1 · Optional

             To indicate that the next segment begins a loop

          7. NM1 Loop Optional Repeat 1

             1. 180 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

                To supply the full name of an individual or organizational entity

             2. 190 · N2 · Additional Name Information · Max 1 · Optional

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

             3. 200 · N3 · Address Information · Max 1 · Optional

                To specify the location of the named party

             4. 210 · N4 · Geographic Location · Max 1 · Optional

                To specify the geographic place of the named party

             5. 220 · PER · Administrative Communications Contact · Max 3 · Optional

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

          8. 225 · LE · Loop Trailer · Max 1 · Optional

             To indicate that the loop immediately preceding this segment is complete

2. 230 · 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).