EDI 269 Health Care Benefit Coordination Verification

Functional Group HV

X12N Insurance Subcommittee

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Benefit Coordination Verification Transaction Set (269) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to transmit and respond to Health Care Benefit coordination information such as claim identification, previous adjudication details, and adjudication verification from one Health Care Payer to another. The transaction can be used as a notification of benefit coordination information. When used as a request for verification of benefit coordination information, the 269 is the response to that request for benefit coordination information verification.

Heading

1. 0100 · ST · Transaction Set Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

2. 0200 · BGN · Beginning Segment · Max 1 · Mandatory

   To indicate the beginning of a transaction set

3. 1000 Loop Mandatory Repeat 2

   1. 0300 · N1 · Party Identification · Max 1 · Mandatory

      To identify a party by type of organization, name, and code

   2. 0400 · N2 · Additional Name Information · Max 1 · Optional

      To specify additional names

   3. 0500 · N3 · Party Location · Max 1 · Optional

      To specify the location of the named party

   4. 0600 · N4 · Geographic Location · Max 1 · Optional

      To specify the geographic place of the named party

   5. 0700 · PER · Administrative Communications Contact · Max 1 · Optional

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

Detail

1. 2000 Loop Mandatory Repeat >1

   1. 0100 · TRN · Trace · Max 1 · Mandatory

      To uniquely identify a transaction to an application

      The TRN segment is used to uniquely identify and tie an inquiry to a response.

   2. 0200 · CLP · Claim Level Data · Max 1 · Optional

      To supply information common to all services of a claim

   3. 0300 · DTP · Date or Time or Period · Max 2 · Optional

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

   4. 0400 · AAA · Request Validation · Max 1 · Optional

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

   5. 2100 Loop Optional Repeat 4

      1. 0500 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

      2. 0600 · N2 · Additional Name Information · Max 1 · Optional

         To specify additional names

      3. 0700 · N3 · Party Location · Max 1 · Optional

         To specify the location of the named party

      4. 0800 · N4 · Geographic Location · Max 1 · Optional

         To specify the geographic place of the named party

      5. 0900 · REF · Reference Information · Max 9 · Optional

         To specify identifying information

      6. 1000 · PER · Administrative Communications Contact · Max 1 · Optional

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

      7. 1100 · DTP · Date or Time or Period · Max 1 · Optional

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

   6. 2200 Loop Optional Repeat 999

      1. 1200 · SVC · Service Information · Max 1 · Mandatory

         To supply payment and control information to a provider for a particular service

      2. 1300 · DTP · Date or Time or Period · Max 1 · Optional

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

2. 1400 · 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)