EDI 271 Eligibility, Coverage or Benefit Information

Functional Group HB

X12N Insurance Subcommittee

This X12 Transaction Set 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. 0100 · ST · Transaction Set Header · Max 1 · Mandatory

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

2. 0200 · 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. 0100 · HL · Hierarchical Level · Max 1 · Mandatory

      To identify dependencies among and the content of hierarchically related groups of data segments

   2. 0200 · 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. 0250 · 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. 0300 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

      2. 0400 · REF · Reference Information · Max 9 · Optional

         To specify identifying information

      3. 0500 · N2 · Additional Name Information · Max 1 · Optional

         To specify additional names

      4. 0600 · N3 · Party Location · Max 1 · Optional

         To specify the location of the named party

      5. 0700 · N4 · Geographic Location · Max 1 · Optional

         To specify the geographic place of the named party

      6. 0800 · PER · Administrative Communications Contact · Max 3 · Optional

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

      7. 0850 · AAA · Request Validation · Max 9 · Optional

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

      8. 0900 · PRV · Provider Information · Max 1 · Optional

         To specify the identifying characteristics of a provider

      9. 1000 · DMG · Demographic Information · Max 1 · Optional

         To supply demographic information

      10. 1100 · INS · Insured Benefit · Max 1 · Optional

          To provide benefit information on insured entities

      11. 1150 · HI · Health Care Information Codes · Max 1 · Optional

          To supply information related to the delivery of health care

      12. 1200 · DTP · Date or Time or Period · Max 9 · Optional

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

      13. 1250 · LUI · Language Use · Max 9 · Optional

          To specify language, type of usage, and proficiency or fluency

      14. 1275 · MPI · Military Personnel Information · Max 9 · Optional

          To report military service data

      15. 2105 Loop Optional Repeat >1

          1. 1290 · LX · Transaction Set Line Number · Max 1 · Mandatory

             To reference a line number in a transaction set

          2. 1295 · DTM · Date/Time Reference · Max 1 · Optional

             To specify pertinent dates and times

          3. 2110 Loop Optional Repeat >1

             1. 1300 · EB · Eligibility or Benefit Information · Max 1 · Mandatory

                To supply eligibility or benefit information

             2. 1320 · SBI · Specific Benefit Information · Max 5 · Optional

                To specify specifc benefit scenarios

             3. 1350 · HSD · Health Care Services Delivery · Max 9 · Optional

                To specify the delivery pattern of health care services

             4. 1400 · REF · Reference Information · Max 9 · Optional

                To specify identifying information

             5. 1500 · DTP · Date or Time or Period · Max 20 · Optional

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

             6. 1600 · AAA · Request Validation · Max 9 · Optional

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

             7. 1700 · VEH · Vehicle Information · Max 1 · Optional

                To provide descriptions that identify a specific vehicle

             8. 1800 · PID · Product/Item Description · Max 1 · Optional

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

             9. 1900 · PDR · Property Description - Real · Max 1 · Optional

                To provide a description of real property

             10. 2000 · PDP · Property Description - Personal · Max 1 · Optional

                 To provide a description of personal property

             11. 2100 · LIN · Item Identification · Max 1 · Optional

                 To specify basic item identification data

             12. 2200 · EM · Equipment Characteristics · Max 1 · Optional

                 To send additional information regarding a specific piece of equipment

             13. 2300 · 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

             14. 2400 · PKD · Packaging Description · Max 1 · Optional

                 To specify a package description and other information

             15. 2500 · MSG · Message Text · Max 10 · Optional

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

             16. 2550 · TOO · Tooth Identification · Max >1 · Optional

                 To identify a tooth by number and, if applicable, one or more tooth surfaces

             17. 2115 Loop Optional Repeat >1

                 1. 2600 · III · Information · Max 1 · Mandatory

                    To report information

                 2. 2700 · DTP · Date or Time or Period · Max 5 · Optional

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

                 3. 2800 · AMT · Monetary Amount Information · Max 5 · Optional

                    To indicate the total monetary amount

                 4. 2900 · PCT · Percent Amounts · Max 5 · Optional

                    To qualify percent amounts and supply percent amounts

                 5. 2117 Loop Optional Repeat >1

                    1. 3000 · LQ · Industry Code Identification · Max 1 · Mandatory

                       To identify standard industry codes

                    2. 3100 · AMT · Monetary Amount Information · Max 5 · Optional

                       To indicate the total monetary amount

                    3. 3200 · PCT · Percent Amounts · Max 5 · Optional

                       To qualify percent amounts and supply percent amounts

             18. 3300 · LS · Loop Header · Max 1 · Optional

                 To indicate that the next segment begins a loop

             19. 2120 Loop Optional Repeat >1

                 1. 3400 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

                    To supply the full name of an individual or organizational entity

                 2. 3500 · N2 · Additional Name Information · Max 1 · Optional

                    To specify additional names

                 3. 3600 · N3 · Party Location · Max 1 · Optional

                    To specify the location of the named party

                 4. 3700 · N4 · Geographic Location · Max 1 · Optional

                    To specify the geographic place of the named party

                 5. 3800 · PER · Administrative Communications Contact · Max 3 · Optional

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

                 6. 3900 · PRV · Provider Information · Max 1 · Optional

                    To specify the identifying characteristics of a provider

             20. 4000 · LE · Loop Trailer · Max 1 · Optional

                 To indicate that the loop immediately preceding this segment is complete

2. 4100 · 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)