EB Eligibility or Benefit Information

To supply eligibility or benefit information

Position: EB-01 · Element: 1390 · Name: Eligibility or Benefit Information Code · Type: Identifier (ID) · Requirement: Mandatory · Min: 1 · Max: 2 · Repeat: 1

Code identifying eligibility or benefit information

EB01 qualifies EB06 through EB10.

Position: EB-02 · Element: 1207 · Name: Coverage Level Code · Type: Identifier (ID) · Requirement: Optional · Min: 3 · Max: 3 · Repeat: 1

Code indicating the level of coverage being provided for this insured

Position: EB-03 · Element: 1365 · Name: Service Type Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 99

Code identifying the classification of service

Position of data in the repeating data element conveys no significance.

Position: EB-04 · Element: 1336 · Name: Insurance Type Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 3 · Repeat: 1

Code identifying the type of insurance policy within a specific insurance program

Position: EB-05 · Element: 1204 · Name: Plan Coverage Description · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 50 · Repeat: 1

A description or number that identifies the plan or coverage

Position: EB-06 · Element: 615 · Name: Time Period Qualifier · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 1

Code defining periods

Position: EB-07 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Optional · Min: 1 · Max: 18 · Repeat: 1

Monetary amount

Position: EB-08 · Element: 954 · Name: Percentage as Decimal · Type: Decimal number (R) · Requirement: Optional · Min: 1 · Max: 10 · Repeat: 1

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

Position: EB-09 · Element: 673 · Name: Quantity Qualifier · Type: Identifier (ID) · Requirement: Conditional · Min: 2 · Max: 2 · Repeat: 1

Code specifying the type of quantity

P0910: If either EB-09 or EB-10 is present, then the other is required

Position: EB-10 · Element: 380 · Name: Quantity · Type: Decimal number (R) · Requirement: Conditional · Min: 1 · Max: 15 · Repeat: 1

Numeric value of quantity

Position: EB-11 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating a Yes or No condition or response

EB11 is the authorization or certification indicator. A "Y" value indicates that an authorization or certification is required per plan provisions. An "N" value indicates that an authorization or certification is not required per plan provisions. A "U" value indicates it is unknown whether the plan provisions require an authorization or certification.

Position: EB-12 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating a Yes or No condition or response

EB12 is the plan network indicator. A "Y" value indicates the benefits identified are considered In-Plan-Network. An "N" value indicates that the benefits identified are considered Out-Of-Plan-Network. A "U" value indicates it is unknown whether the benefits identified are part of the Plan Network.

EB-13 C003 Composite Medical Procedure Identifier Composite (composite) Optional 1

Position: 01 · Element: 235 · Name: Product/Service ID Qualifier · Type: Identifier (ID) · Requirement: Mandatory · Min: 2 · Max: 2 · Repeat: -

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

Position: 02 · Element: 234 · Name: Product/Service ID · Type: String (AN) · Requirement: Mandatory · Min: 1 · Max: 48 · Repeat: -

Identifying number for a product or service

Position: 03 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-03 modifies the value in C003-02.

Position: 04 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-04 modifies the value in C003-02.

Position: 05 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-05 modifies the value in C003-02.

Position: 06 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-06 modifies the value in C003-02.

Position: 07 · Element: 352 · Name: Description · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 80 · Repeat: -

A free-form description to clarify the related data elements and their content

C003-07 is the description of the procedure identified in C003-02.

EB-14 C004 Composite Diagnosis Code Pointer Composite (composite) Optional 1

Position: 01 · Element: 1328 · Name: Diagnosis Code Pointer · Type: Numeric (N0) · Requirement: Mandatory · Min: 1 · Max: 2 · Repeat: -

A pointer to the diagnosis code in the order of importance to this service

C004-01 identifies the primary diagnosis code for this service line.

Position: 02 · Element: 1328 · Name: Diagnosis Code Pointer · Type: Numeric (N0) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: -

A pointer to the diagnosis code in the order of importance to this service

C004-02 identifies the second diagnosis code for this service line.

Position: 03 · Element: 1328 · Name: Diagnosis Code Pointer · Type: Numeric (N0) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: -

A pointer to the diagnosis code in the order of importance to this service

C004-03 identifies the third diagnosis code for this service line.

Position: 04 · Element: 1328 · Name: Diagnosis Code Pointer · Type: Numeric (N0) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: -

A pointer to the diagnosis code in the order of importance to this service

C004-04 identifies the fourth diagnosis code for this service line.