EDI 270 Eligibility, Coverage or Benefit Inquiry

Functional Group HS

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Eligibility, Coverage or 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 eligibility, coverages or benefits associated with a benefit plan, employer, plan sponsor, subscriber or a dependent under the subscriber's policy. The transaction set is intended to be used by all lines of insurance such as Health, Life, and Property and Casualty.

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 · BHT · Beginning of Hierarchical Transaction · Max 1 · Mandatory

   To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

Detail

1. 2000 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

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

      To uniquely identify a transaction to an application

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

   3. 2100 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 Identification · Max 9 · Optional

         To specify identifying information

      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

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

         To supply demographic information

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

         To provide benefit information on insured entities

      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. 2110 Loop Optional Repeat 99

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

             To specify inquired eligibility or benefit information

          2. 135 · AMT · Monetary Amount · Max 2 · Optional

             To indicate the total monetary amount

          3. 140 · VEH · Vehicle Information · Max 1 · Optional

             To provide descriptions that identify a specific vehicle

          4. 150 · PDR · Property Description - Real · Max 1 · Optional

             To provide a description of real property

          5. 160 · PDP · Property Description - Personal · Max 1 · Optional

             To provide a description of personal property

          6. 170 · III · Information · Max 10 · Optional

             To report information

          7. 190 · REF · Reference Identification · Max 1 · Optional

             To specify identifying information

          8. 200 · DTP · Date or Time or Period · Max 9 · Optional

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

2. 210 · 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)