EDI 271 Eligibility, Coverage or Benefit Information
Functional Group HB
X12N Insurance Subcommittee
This Draft Standard for Trial Use contains the format and establishes the data contents of the Eligibility, Coverage or 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 information about or changes to eligibility, coverage or benefits from information sources (such as - insurers, sponsors, payors) to information receivers (such as - physicians, hospitals, repair facilities, third party administrators, governmental agencies). This information includes but is not limited to: benefit status, explanation of benefits, coverages, dependent coverage level, effective dates, amounts for co-insurance, co-pays, deductibles, exclusions and limitations.
Heading
- 010Transaction Set HeaderMandatoryMax 1
To indicate the start of a transaction set and to assign a control number
- 020Beginning of Hierarchical TransactionMandatoryMax 1
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
- 2000 Loop MandatoryRepeat >1
- 010Hierarchical LevelMandatoryMax 1
To identify dependencies among and the content of hierarchically related groups of data segments
- 020TraceOptionalMax 9
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. - 025Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
- 2100 Loop OptionalRepeat >1
- 030Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 040Reference IdentificationOptionalMax 9
To specify identifying information
- 050Additional Name InformationOptionalMax 1
To specify additional names or those longer than 35 characters in length
- 060Address InformationOptionalMax 1
To specify the location of the named party
- 070Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 080Administrative Communications ContactOptionalMax 3
To identify a person or office to whom administrative communications should be directed
- 085Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
- 090Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
- 100Demographic InformationOptionalMax 1
To supply demographic information
- 110Insured BenefitOptionalMax 1
To provide benefit information on insured entities
- 120Date or Time or PeriodOptionalMax 9
To specify any or all of a date, a time, or a time period
- 2110 Loop OptionalRepeat >1
- 130Eligibility or Benefit InformationMandatoryMax 1
To supply eligibility or benefit information
- 135Health Care Services DeliveryOptionalMax 9
To specify the delivery pattern of health care services
- 140Reference IdentificationOptionalMax 9
To specify identifying information
- 150Date or Time or PeriodOptionalMax 20
To specify any or all of a date, a time, or a time period
- 160Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
- 170Vehicle InformationOptionalMax 1
To provide descriptions that identify a specific vehicle
- 180Product/Item DescriptionOptionalMax 1
To describe a product or process in coded or free-form format
- 190Property Description - RealOptionalMax 1
To provide a description of real property
- 200Property Description - PersonalOptionalMax 1
To provide a description of personal property
- 210Item IdentificationOptionalMax 1
To specify basic item identification data
- 220Equipment CharacteristicsOptionalMax 1
To send additional information regarding a specific piece of equipment
- 230Safety DataOptionalMax 1
To provide safety data information to recipients of the transaction, including identification of the hazard that the material being described represents, and the organization or party which declared this material to be a hazard or established exposure limits or other guidelines for that material
- 240Packaging DescriptionOptionalMax 1
To specify a package description and other information
- 250Message TextOptionalMax 10
To provide a free-form format that allows the transmission of text information
- 2115 Loop OptionalRepeat >1
- 260InformationMandatoryMax 0
To report information
- 270Date or Time or PeriodOptionalMax 5
To specify any or all of a date, a time, or a time period
- 280Monetary AmountOptionalMax 5
To indicate the total monetary amount
- 290Percent AmountsOptionalMax 5
To qualify percent amounts and supply percent amounts
- 2117 Loop OptionalRepeat >1
- 300Industry CodeMandatoryMax 1
Code to transmit standard industry codes
- 310Monetary AmountOptionalMax 5
To indicate the total monetary amount
- 320Percent AmountsOptionalMax 5
To qualify percent amounts and supply percent amounts
- 300Industry CodeMandatoryMax 1
- 260InformationMandatoryMax 0
- 330Loop HeaderOptionalMax 1
To indicate that the next segment begins a loop
- 2120 Loop OptionalRepeat 1
- 340Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 350Additional Name InformationOptionalMax 1
To specify additional names or those longer than 35 characters in length
- 360Address InformationOptionalMax 1
To specify the location of the named party
- 370Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 380Administrative Communications ContactOptionalMax 3
To identify a person or office to whom administrative communications should be directed
- 390Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
- 340Individual or Organizational NameMandatoryMax 1
- 400Loop TrailerOptionalMax 1
To indicate that the loop immediately preceding this segment is complete
- 130Eligibility or Benefit InformationMandatoryMax 1
- 030Individual or Organizational NameMandatoryMax 1
- 010Hierarchical LevelMandatoryMax 1
- 410Transaction Set TrailerMandatoryMax 1
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)