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

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

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

   4. 2100 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 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. 085 · AAA · Request Validation · Max 9 · Optional

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

      8. 090 · PRV · Provider Information · Max 1 · Optional

         To specify the identifying characteristics of a provider

      9. 100 · DMG · Demographic Information · Max 1 · Optional

         To supply demographic information

      10. 110 · INS · Insured Benefit · Max 1 · Optional

          To provide benefit information on insured entities

      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. 2110 Loop Optional Repeat >1

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

             To supply eligibility or benefit information

          2. 135 · HSD · Health Care Services Delivery · Max 9 · Optional

             To specify the delivery pattern of health care services

          3. 140 · REF · Reference Identification · Max 9 · Optional

             To specify identifying information

          4. 150 · DTP · Date or Time or Period · Max 20 · Optional

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

          5. 160 · AAA · Request Validation · Max 9 · Optional

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

          6. 170 · VEH · Vehicle Information · Max 1 · Optional

             To provide descriptions that identify a specific vehicle

          7. 180 · PID · Product/Item Description · Max 1 · Optional

             To describe a product or process in coded or free-form format

          8. 190 · PDR · Property Description - Real · Max 1 · Optional

             To provide a description of real property

          9. 200 · PDP · Property Description - Personal · Max 1 · Optional

             To provide a description of personal property

          10. 210 · LIN · Item Identification · Max 1 · Optional

              To specify basic item identification data

          11. 220 · EM · Equipment Characteristics · Max 1 · Optional

              To send additional information regarding a specific piece of equipment

          12. 230 · SD1 · Safety Data · Max 1 · Optional

              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

          13. 240 · PKD · Packaging Description · Max 1 · Optional

              To specify a package description and other information

          14. 250 · MSG · Message Text · Max 10 · Optional

              To provide a free-form format that allows the transmission of text information

          15. 2115 Loop Optional Repeat >1

              1. 260 · III · Information · Max 1 · Mandatory

                 To report information

              2. 270 · DTP · Date or Time or Period · Max 5 · Optional

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

              3. 280 · AMT · Monetary Amount · Max 5 · Optional

                 To indicate the total monetary amount

              4. 290 · PCT · Percent Amounts · Max 5 · Optional

                 To qualify percent amounts and supply percent amounts

              5. 2117 Loop Optional Repeat >1

                 1. 300 · LQ · Industry Code · Max 1 · Mandatory

                    Code to transmit standard industry codes

                 2. 310 · AMT · Monetary Amount · Max 5 · Optional

                    To indicate the total monetary amount

                 3. 320 · PCT · Percent Amounts · Max 5 · Optional

                    To qualify percent amounts and supply percent amounts

          16. 330 · LS · Loop Header · Max 1 · Optional

              To indicate that the next segment begins a loop

          17. 2120 Loop Optional Repeat 1

              1. 340 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

                 To supply the full name of an individual or organizational entity

              2. 350 · N2 · Additional Name Information · Max 1 · Optional

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

              3. 360 · N3 · Address Information · Max 1 · Optional

                 To specify the location of the named party

              4. 370 · N4 · Geographic Location · Max 1 · Optional

                 To specify the geographic place of the named party

              5. 380 · PER · Administrative Communications Contact · Max 3 · Optional

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

              6. 390 · PRV · Provider Information · Max 1 · Optional

                 To specify the identifying characteristics of a provider

          18. 400 · LE · Loop Trailer · Max 1 · Optional

              To indicate that the loop immediately preceding this segment is complete

2. 410 · 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)