ASC X12N/005010X279

Based on Version 5, Release 1

ASC X12 Standards for Electronic Data Interchange

Technical Report Type 3

Health Care Eligibility Benefit

Inquiry and Response
(270/271)
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HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE TECHNICAL REPORT • TYPE 3

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Table of Contents
1 Purpose and Business Information ............................... 1
1.1 Implementation Purpose and Scope......................................... 1
1.2 Version Information.......................................................................... 1
1.3 Implementation Limitations .......................................................... 2
1.3.1 Batch and Real-time Usage..................................................... 2
1.3.2 Other Usage Limitations ......................................................... 2
1.4 Business Usage ................................................................................. 3
1.4.1 Background Information ......................................................... 3
1.4.2 Basic Concepts ........................................................................ 5
1.4.3 Batch and Real Time................................................................ 8
1.4.4 Supported Business Functions ............................................ 10
1.4.5 Unsupported Business Functions ....................................... 14
1.4.6 Information Linkage............................................................... 15
1.4.6.1 Real Time Linkage .................................................. 15
1.4.6.2 Batch Linkage......................................................... 16
1.4.7 Implementation-Compliant Use of the 270/271
Transaction Set ...................................................................... 18
1.4.7.1 Minimum Requirements For Implementation
Guide Compliance .................................................. 19
1.4.7.2 Recommended Additional Support ......................... 22
1.4.7.3 Streamlining Responses......................................... 24
1.4.7.4 Person Specific Benefit Responses ....................... 24
1.4.7.5 Patient History Benefit Responses ......................... 24
1.4.8 Search Options ...................................................................... 25
1.4.8.1 Required Primary Search Options .......................... 25
1.4.8.2 Required Alternate Search Options ........................ 26
1.4.8.3 Name/Date of Birth Search Option ......................... 28
1.4.8.4 Member ID Number/Date of Birth Search
Option ..................................................................... 30
1.4.8.5 Additional Alternate Search Options ....................... 32
1.4.8.6 Insufficient Identifying Elements ............................. 33
1.4.8.7 Multiple Matches..................................................... 33
1.4.9 Patient Responsibility ........................................................... 33
1.4.10 Rejected Transactions ........................................................... 36
1.4.11 Disclaimers Within the Transactions ................................... 37
1.4.12 Message Segments................................................................ 37
1.4.13 Information Flows .................................................................. 37
1.4.13.1 Basic Information Flow ........................................... 37
1.4.13.2 Intermediaries ......................................................... 38
1.4.13.3 Multiple Intermediaries............................................ 38
1.4.13.4 Multiple Responders ............................................... 39
1.4.13.5 Value Added Service Organizations ....................... 39
1.4.13.6 Complex Requester Environments......................... 40
1.5 Business Terminology .................................................................. 41
1.6 Transaction Acknowledgments................................................. 42
1.6.1 997 Functional Acknowledgment ......................................... 43
1.6.2 999 Implementation Acknowledgment................................. 43

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1.6.3 824 Application Reporting..................................................... 43

1.7 Related Transactions ..................................................................... 44
1.8 Trading Partner Agreements ...................................................... 44
1.9 HIPAA Role in Implementation Guides................................... 44
1.10 Data Overview .................................................................................. 45
1.10.1 Overall Data Architecture ...................................................... 45
1.10.2 Data Use by Business Use.................................................... 45
1.11 HIPAA Privacy ................................................................................... 45
1.12 About the Authors .......................................................................... 46

2 Transaction Sets ........................................................................ 47

2.1 Presentation Examples................................................................. 47
2.2 Implementation Usage .................................................................. 52
2.2.1 Industry Usage ....................................................................... 52
2.2.1.1 Transaction Compliance Related to Industry
Usage ..................................................................... 53
2.2.2 Loops ...................................................................................... 53
2.3 Transaction Set Listing ................................................................. 55
2.3.1 Implementation ...................................................................... 55
2.3.2 X12 Standard .......................................................................... 58
2.4 270 Segment Detail......................................................................... 60
ST Transaction Set Header.......................................... 61
BHT Beginning of Hierarchical Transaction .................... 63
HL Information Source Level........................................ 66
NM1 Information Source Name....................................... 69
HL Information Receiver Level ..................................... 72
NM1 Information Receiver Name.................................... 75
REF Information Receiver Additional Identification......... 79
N3 Information Receiver Address ................................ 81
N4 Information Receiver City, State, ZIP Code ............ 82
PRV Information Receiver Provider Information ............. 84
HL Subscriber Level..................................................... 86
TRN Subscriber Trace Number....................................... 90
NM1 Subscriber Name.................................................... 92
REF Subscriber Additional Identification......................... 97
N3 Subscriber Address .............................................. 100
N4 Subscriber City, State, ZIP Code .......................... 101
PRV Provider Information ............................................. 103
DMG Subscriber Demographic Information ................... 107
INS Multiple Birth Sequence Number .......................... 110
HISubscriber Health Care Diagnosis Code.............. 113
DTP Subscriber Date.................................................... 122
EQ Subscriber Eligibility or Benefit Inquiry ................. 124
AMT Subscriber Spend Down Amount.......................... 136
AMT Subscriber Spend Down Total Billed Amount ....... 137
III
Subscriber Eligibility or Benefit Additional
Inquiry Information ................................................ 138
REF Subscriber Additional Information ......................... 142

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DTP Subscriber Eligibility/Benefit Date......................... 144

HL Dependent Level .................................................. 146
TRN Dependent Trace Number .................................... 149
NM1 Dependent Name ................................................. 151
REF Dependent Additional Identification ...................... 154
N3 Dependent Address .............................................. 157
N4 Dependent City, State, ZIP Code.......................... 158
PRV Provider Information ............................................. 160
DMG Dependent Demographic Information................... 164
INS Dependent Relationship ....................................... 167
HIDependent Health Care Diagnosis Code ............. 170
DTP Dependent Date ................................................... 179
EQ Dependent Eligibility or Benefit Inquiry ................. 181
III
Dependent Eligibility or Benefit Additional
Inquiry Information ................................................ 192
REF Dependent Additional Information......................... 196
DTP Dependent Eligibility/Benefit Date ........................ 198
SE Transaction Set Trailer.......................................... 200
2.5 Transaction Set Listing ............................................................... 201
2.5.1 Implementation .................................................................... 201
2.5.2 X12 Standard ........................................................................ 205
2.6 271 Segment Detail....................................................................... 208
ST Transaction Set Header........................................ 209
BHT Beginning of Hierarchical Transaction .................. 211
HL Information Source Level...................................... 213
AAA Request Validation................................................ 215
NM1 Information Source Name..................................... 218
PER Information Source Contact Information ............... 221
AAA Request Validation................................................ 226
HL Information Receiver Level ................................... 229
NM1 Information Receiver Name.................................. 232
REF Information Receiver Additional Identification....... 236
AAA Information Receiver Request Validation.............. 238
PRV Information Receiver Provider Information ........... 241
HL Subscriber Level................................................... 243
TRN Subscriber Trace Number..................................... 246
NM1 Subscriber Name.................................................. 249
REF Subscriber Additional Identification....................... 253
N3 Subscriber Address .............................................. 257
N4 Subscriber City, State, ZIP Code .......................... 259
AAA Subscriber Request Validation.............................. 262
PRV Provider Information ............................................. 265
DMG Subscriber Demographic Information ................... 268
INS Subscriber Relationship........................................ 271
HI Subscriber Health Care Diagnosis Code.............. 274
DTP Subscriber Date.................................................... 283
MPI Subscriber Military Personnel Information ............ 285
EB Subscriber Eligibility or Benefit Information .......... 289
HSD Health Care Services Delivery.............................. 309
REF Subscriber Additional Identification....................... 314
DTP Subscriber Eligibility/Benefit Date......................... 317
AAA Subscriber Request Validation.............................. 319
MSG Message Text........................................................ 322

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III Subscriber Eligibility or Benefit Additional

Information............................................................ 324
LS Loop Header......................................................... 328
NM1 Subscriber Benefit Related Entity Name .............. 329
N3 Subscriber Benefit Related Entity Address ........... 335
N4 Subscriber Benefit Related Entity City, State,
ZIP Code .............................................................. 336
PER Subscriber Benefit Related Entity Contact
Information............................................................ 339
PRV Subscriber Benefit Related Provider
Information............................................................ 344
LE Loop Trailer........................................................... 346
HL Dependent Level .................................................. 347
TRN Dependent Trace Number .................................... 351
NM1 Dependent Name ................................................. 354
REF Dependent Additional Identification ...................... 357
N3 Dependent Address .............................................. 361
N4 Dependent City, State, ZIP Code.......................... 363
AAA Dependent Request Validation ............................. 366
PRV Provider Information ............................................. 369
DMG Dependent Demographic Information................... 372
INS Dependent Relationship ....................................... 375
HI Dependent Health Care Diagnosis Code ............. 378
DTP Dependent Date ................................................... 387
MPI Dependent Military Personnel Information............ 389
EB Dependent Eligibility or Benefit Information.......... 393
HSD Health Care Services Delivery.............................. 412
REF Dependent Additional Identification ...................... 417
DTP Dependent Eligibility/Benefit Date ........................ 420
AAA Dependent Request Validation ............................. 422
MSG Message Text........................................................ 425
III Dependent Eligibility or Benefit Additional
Information............................................................ 427
LS Loop Header......................................................... 431
NM1 Dependent Benefit Related Entity Name.............. 432
N3 Dependent Benefit Related Entity Address .......... 438
N4 Dependent Benefit Related Entity City, State,
ZIP Code .............................................................. 439
PER Dependent Benefit Related Entity Contact
Information............................................................ 442
PRV Dependent Benefit Related Provider
Information............................................................ 447
LE Loop Trailer........................................................... 449
SE Transaction Set Trailer.......................................... 450

3 Examples ....................................................................................... 451

3.1 Example 1 ......................................................................................... 452
3.1.1 Request................................................................................. 452
3.1.2 Response.............................................................................. 454
3.1.3 Response.............................................................................. 457

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3.2 Example 2 ......................................................................................... 458

3.2.1 Request................................................................................. 458
3.2.2 Response.............................................................................. 461

A External Code Sources ........................................................A.1

5 Countries, Currencies and Funds .......................................A.1
22 States and Provinces............................................................A.2
51 ZIP Code ................................................................................A.3
130 Healthcare Common Procedural Coding System ..............A.3
131 International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM) .........................................A.4
133 Current Procedural Terminology (CPT) Codes ..................A.4
135 American Dental Association ..............................................A.5
206 Government Bill of Lading Office Code ..............................A.5
237 Place of Service Codes for Professional Claims ...............A.6
240 National Drug Code by Format ............................................A.6
284 Nature of Injury Code ...........................................................A.7
307 National Council for Prescription Drug Programs
Pharmacy Number ................................................................A.7
407 Occupational Injury and Illness Classification Manual .....A.8
513 Home Infusion EDI Coalition (HIEC) Product/Service
Code List................................................................................A.9
537 Centers for Medicare and Medicaid Services National
Provider Identifier .................................................................A.9
540 Centers for Medicare and Medicaid Services PlanID ......A.10
682 Health Care Provider Taxonomy........................................A.10
844 Eligibility Category ............................................................. A.11
896 International Classification of Diseases, 10th
Revision, Procedure Coding System (ICD-10-PCS)......... A.11
897 International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM) ....................A.12
932 Universal Postal Codes ......................................................A.12
DOD1 Military Rank and Health Care Service Region ................A.13
DOD2 Paygrade..............................................................................A.13

B Nomenclature..............................................................................B.1
B.1 ASC X12 Nomenclature ...............................................................B.1
B.1.1 Interchange and Application Control Structures ...............B.1
B.1.1.1 Interchange Control Structure ...............................B.1
B.1.1.2 Application Control Structure Definitions and
Concepts ...............................................................B.2
B.1.1.3 Business Transaction Structure Definitions and
Concepts ...............................................................B.6
B.1.1.4 Envelopes and Control Structures.......................B.19
B.1.1.5 Acknowledgments ...............................................B.22
B.2 Object Descriptors.......................................................................B.23

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C EDI Control Directory ............................................................C.1

C.1 Control Segments ..........................................................................C.1
ISA Interchange Control Header.................................................C.3
GS Functional Group Header .....................................................C.7
GE Functional Group Trailer ......................................................C.9
IEA Interchange Control Trailer ................................................C.10

D Change Summary ....................................................................D.1

E Data Element Glossary ........................................................E.1

E.1 Data Element Name Index ..........................................................E.1

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1 Purpose and Business Information

1.1 Implementation Purpose and Scope
For the health care industry to achieve the potential administrative cost savings with
Electronic Data Interchange (EDI), standards have been developed and need to be
implemented consistently by all organizations. To facilitate a smooth transition into the
EDI environment, uniform implementation is critical.

The purpose of this implementation guide is to explain the developers' intent when the
Health Care Eligibility, Coverage, or Benefit Inquiry (270) and Health Care Eligibility,
Coverage, or Benefit Information (271) transaction sets were designed and to give
guidance on how they should be implemented in the health care industry. Specifically,
this guide defines where data is put and when it is included for the ANSI ASC X12.281
and X12.282 transaction sets for the purpose of conveying health care eligibility and
benefit information. This paired transaction set is comprised of two transactions: the
270, which is used to request (inquire) information, and the 271, which is used to respond
with coverage, eligibility, and benefit information. The official names for these transactions
are:

ANSI ASC X12.281 - Eligibility, Coverage, or Benefit Inquiry (270)

ANSI ASC X12.282 - Eligibility, Coverage, or Benefit Information (271)

This implementation guide is intended to provide assistance in the development and

use of the electronic transfer of health care eligibility and benefit information. It is hoped
that the entities that exchange eligibility information will work to develop and exchange
standard formats within the health care industry and among their trading partners.

1.2 Version Information

This implementation guide is based on the October 2003 ASC X12 standards, referred
to as Version 5, Release 1, Sub-release 0 (005010).

The unique Version/Release/Industry Identifier Code for transaction sets that are defined
by this implementation guide is 005010X279.

The two-character Functional Identifier Codes for the transaction sets included in this
implementation guide:

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• HB Eligibility, Coverage or Benefit Information (271)

• HS Eligibility, Coverage or Benefit Inquiry (270)

The Version/Release/Industry Identifier Code and the applicable Functional Identifier

Code must be transmitted in the Functional Group Header (GS segment) that begins a
functional group of these transaction sets. For more information, see the descriptions
of GS01 and GS08 in Appendix C, EDI Control Directory.

1.3 Implementation Limitations

1.3.1 Batch and Real-time Usage
There are multiple methods available for sending and receiving business transactions
electronically. Two common modes for EDI transactions are batch and real-time.

Batch - In a batch mode the sender does not remain connected while the receiver
processes the transactions. Processing is usually completed according to a set schedule.
If there is an associated business response transaction (such as a 271 Response to a
270 Request for Eligibility), the receiver creates the response transaction and stores it
for future delivery. The sender of the original transmission reconnects at a later time and
picks up the response transaction. This implementation guide does not set specific
response time parameters for these activities.

Real Time - In real-time mode the sender remains connected while the receiver processes
the transactions and returns a response transaction to the sender. This implementation
guide does not set specific response time parameters for implementers.

This implementation guide is intended to support use in batch and real-time mode. A
statement that the transaction is not intended to support a specific mode does not
preclude its use in that mode between willing trading partners.

1.3.2 Other Usage Limitations

Batch
It is required that the 270 transaction contains no more than ninety-nine patient requests
when using the transaction in a batch mode (See the Exceeding The Number of Patient
Requests section below for the exception). In a batch mode, it is possible to have patient
requests in both the subscriber and dependent levels (e.g. subscriber and spouse). In
a batch mode it is also possible to have more than one dependent patient requests (e.g.
twins). In the case where there are patient requests at both the subscriber and dependent

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levels or for multiple dependents, each patient request counts as one patient request
toward the maximum number of ninety-nine patient requests (See Section 1.4.2 Patient
subsection for additional information).

Real Time
It is required that the 270 transaction contain only one patient request when using the
transaction in a real time mode (See the Exceeding The Number of Patient Requests
section below for the exception). One patient is defined as either, one subscriber loop
if the member is the patient, or one dependent loop if the dependent is the patient (See
Section 1.4.2 Patient subsection for additional information).

Exceeding The Number of Patient Requests

Although it is not recommended, if the number of patients is to be greater than one for
real time mode or greater than ninety-nine for batch mode, the trading partners (the
Information Source, the Information Receiver and the switch the transaction is routed
through, if there is one involved) must all agree to exceed the number of recommended
patient requests and agree to a reasonable limit.

In the event the Information Receiver exceeds the maximum number of patient requests
allowed, two possible scenarios arise. First, if the processor of the transaction (either
the switch or the Information Source) detects the maximum has been exceeded, a 271
with a AAA segment with element AAA03 containing a code value "04" (Authorized
Quantity Exceeded) will be issued. If this has been detected by a switch, use the AAA
segment in the Information Source Level (Loop 2000A). If this has been detected by an
Information Source, use the AAA segment in the Information Source Name loop (Loop
2100A). Second, the processor's system may actually fail, in which case it may not be
possible to send any message back and trading partners should be aware of this
possibility.

1.4 Business Usage

1.4.1 Background Information
Providers of medical services must currently submit health care eligibility and benefit
inquiries in a variety of methods, either on paper, via phone, or electronically. The
information requirements vary depending upon:

• type of insurance plan

• type of service performed

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• where the service is performed

• where the inquiry is initiated
• where the inquiry is sent

The Health Care Eligibility and Benefit transactions are designed so that inquiry submitters
(information receivers) can determine (a) whether an information source organization
(e.g., payer, employer, HMO) has a particular subscriber or dependent on file, and (b)
the health care eligibility and/or benefit information about that subscriber and/or
dependent(s). The data available through these transaction sets is used to verify an
individual's eligibility and benefits, but cannot provide a history of benefit use. The
information source organization may provide information about other organizations that
may have third party liability for coordination of benefits. Note, the identification of
subscriber/dependent and associated relationship code values may or may not be the
values needed to determine primary/secondary coverage for coordination of benefits on
claims transactions.

To accomplish this, two Health Care Eligibility and Benefit transaction sets are used.
The two ASC X12 transaction sets are:

• Health Care Eligibility and Benefit Inquiry (270) from a submitter (information receiver)
to an information source organization
• Health Care Eligibility and Benefit Information (271) from an information source
organization to a submitter (information receiver)

The eligibility transaction sets are designed to be flexible enough to encompass all the
information requirements of the various entities. These entities may include:

• insurance companies
• health maintenance organizations (HMOs)
• preferred provider organizations (PPOs)
• health care purchasers (i.e., employers)
• professional review organizations (PROs)
• social worker organizations
• health care providers (e.g., physicians, hospitals, laboratories)
• third-party administrators (TPAs)
• health care vendors (e.g., practice management vendors, billing services)

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• service bureaus (VANs or VABs)

• government agencies such as Medicare, Medicaid, and Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS)

Some submitters do not have ready access to enough information to generate an inquiry
to a payer. An outside lab or pharmacy providing services to an institution may need to
send an inquiry to the institutional provider to obtain enough information to identify to
which payer a health care eligibility or benefit inquiry should be routed. Because of this
type of situation, a 270 may be originated by a provider and sent to another provider, if
the inquiry is supported by the receiving provider.

1.4.2 Basic Concepts

Information Source (2000A loop)
The information source is the entity that has the answer to the questions being asked
in a 270 Eligibility or Benefit transaction. The information source is typically the insurer,
or payer. In a managed care environment, the information source could possibly be a
primary care physician or gateway provider. Regardless of the information source's
actual role, they are the entity who maintains the information regarding the patient's
coverage. The information source is not a clearinghouse, value added network or other
intermediary, even if they hold the data for the true information source. The information
source's role in the transaction is identified in the Information Source Name segment
(2100A loop NM1).

Information Receiver (2000B loop)

The information receiver is the entity that is asking the questions in a 270 Eligibility or
Benefit transaction. The information receiver is typically the medical service provider
(e.g., physician, hospital, pharmacy, DME supplier, laboratory, etc.). The information
receiver could also be another insurer or payer when they are attempting to verify other
insurance coverage for their members. The information receiver could also be an
employer inquiring on coverage of an employee. The information receiver's role in the
transaction is identified in the Information Receiver Name segment (2100B NM1).

Subscriber (2000C loop)

The subscriber is a person who can be uniquely identified to an information source by
a unique Member Identification Number (which may include a unique suffix to the primary
policy holder's identification number). The subscriber may or may not be the patient.
See definition of patient below for further detail.

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For example, Joe Smith is the primary policy holder and has a Member ID 1234501. He
is considered a subscriber. Joe's wife, Jane Smith, is covered under Joe's policy and
has a Member ID 1234502. Jane is considered a subscriber as well since she has a
unique Member ID number (in this case the suffix is different).

NOTE
The terms Member Identification Number, Member ID Number and Member ID are used
throughout this Implementation Guide. In addition to numeric values, they may contain
characters associated with data type AN. See Appendix B Section B.1.1.3.1.4 - String
for additional information.

Dependent (2000D loop)

The dependent is a person who cannot be uniquely identified to an information source
by a unique Member Identification Number, but can be identified by an information source
when associated with a subscriber. See definition of patient below for further detail.

For example, John Jones is the primary policy holder and has a Member ID 54321. He
is considered a subscriber. John's wife, Susan Jones, is covered under John's policy
and has a Member ID 54321. Susan is considered a dependent since she does not have
a unique Member ID number and must be associated with John's Member ID number.

Patient
There is no HL loop dedicated to patient, rather, the patient can be either the subscriber
or the dependent. Different types of information sources identify patients in different
manners depending upon how their eligibility system is structured.There are two common
approaches for the identification of patients by an information source.

The first approach is to assign each member of the family (and plan) a unique ID number.
This number can be used to identify and access that individual's information independent
of whether he or she is a child, spouse, or the actual subscriber to the plan. In this
approach, the patient will be identified at the subscriber hierarchical level because a
unique ID number exists to access eligibility information for this individual.

Some health plans create a suffix for each individual and append it to the end of the
primary subscriber's identification number, which constitutes a unique ID number for the
purposes of the 270/271 transaction making each individual uniquely identifiable to the
information source.

The second approach is either to assign the actual member or contract holder (the
primary subscriber) a unique ID number or utilize an existing number of theirs (such as
Social Security Number or Employee Identification Number). This number is entered

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into the eligibility system. Any related spouse, children, or dependents are identified
through the primary subscriber's identification number and have no unique identification
number of their own. In this approach, the primary subscriber would be identified at the
subscriber level (2000C loop) and the actual patient (spouse, child, etc.) would be
identified at the dependent level (2000D loop) which is sub-ordinate to the subscriber
(2000C) loop.

Patient Request (2110C or 2110D)

The patient request is defined as the occurrence of one or more 2110 (EQ) loops for an
individual. If the patient is the subscriber, the patient request is the existence of at least
one 2110C loop. If the patient is the dependent, the patient request is the existence of
at least one 2110D loop. In the event the patient has more than one occurrence of a
2110 (EQ) loop, that still constitutes one patient request.

Patient Response (2110C or 2110D)

The patient response is defined as the occurrence of one or more 2110 (EB) loops for
an individual. If the patient is submitted as the subscriber and the Information Source
locates the patient and determines that they are actually a dependent, the primary
subscriber is to be returned in the 2100C loop and the patient is to be returned in the
2100D loop with the patient response information located in the 2110D loop.

Relationship to Subsequent X12 Transactions

One other factor Information Sources need to bear in mind is how they need the patient
submitted in subsequent transactions such as a 278 Health Care Services Request for
Review or an 837 Health Care Claim. The 278 transaction follows a similar model that
if the patient can be uniquely identified they are considered the subscriber. Some
Information Source's 837 claim processes however require Subscriber and Dependent
information if the patient is a dependent, even if the dependent has their own unique ID.
If the individual patient must be submitted as a subscriber in an 837 transaction, then
the Information Source must return the patient in the 271 as the subscriber. If the
individual patient must be submitted as a dependent in an 837 transaction, then the
Information Source must return the patient in the 271 as a dependent. This enables the
provider to populate their practice management system with the proper information to
submit an 837 transaction. The patient must be returned in the correct loop (2000C or
2000D) based on how the Information Source requires the individual be submitted in
subsequent transactions.

Patient Submitted as Subscriber But Returned as Dependent

If the patient is submitted as the subscriber in the 270 transaction and the Information
Source locates the patient and determines that they are actually a dependent, the primary

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subscriber is to be returned in the 271 2100C loop and the patient is to be returned in
the 271 2100D loop with the patient response information located in the 2110D loop.
See Section 1.4.7.1 - Minimum Requirements For Implementation Guide Compliance
271 item 4 for additional information.

If a TRN segment was submitted in the 270 2000C loop, it must be returned in the 271
2000D loop. If a REF segment with REF01 = "EJ" was submitted in the 270 2100C loop,
it must be returned in the 271 2100D loop. See Section 1.4.6 - Information Linkage.

Patient Submitted as Dependent But Returned as Subscriber

If the patient is submitted as the dependent in the 270 transaction and the Information
Source locates the patient and determines that they are actually a subscriber, the patient
is to be returned in the 271 2100C loop. See Section 1.4.7.1 - Minimum Requirements
For Implementation Guide Compliance 271 item 4 for additional information.

If a TRN segment was submitted in the 270 2000D loop, it must be returned in the 271
2000C loop. If a REF segment with REF01 = "EJ" was submitted in the 270 2100D loop,
it must be returned in the 271 2100C loop. See Section 1.4.6 - Information Linkage.

1.4.3 Batch and Real Time

Within telecommunications, there are multiple methods used for sending and receiving
business transactions. Frequently, different methods involve different timings. Two
methods applicable for EDI transactions are batch and real time. The 270/271 Health
Care Eligibility Benefit Inquiry and Response transactions can be used in either a batch
mode or in a real time mode.

Batch
When transactions are used in batch mode, they are typically grouped together in large
quantities and processed en-masse. Typically, the results of a transaction that is
processed in a batch mode would be completed for the next business day if it has been
received by a predetermined cut off time.

Important: When in batch mode, the 999 Implementation Acknowledgment transaction

must be returned as quickly as possible to acknowledge that the receiver has or has not
successfully received the batch transaction. In addition, the TA1 segment must be
supported for interchange level errors (see Section B.1.1.5.1 - Interchange
Acknowledgment, TA1 for details).

If the transaction set is to be used in a batch mode, the Information Receiver sends the
270 to the Information Source, typically through a clearinghouse (switch), but does not

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remain connected while the Information Source processes the transactions. The
Information Source creates a 271 for the Information Receiver off-line. The Information
Receiver typically reconnects at a later time (the amount of time is determined by the
information source or clearinghouse) and picks up the 271. It is required that the 270
transaction contains no more than ninety-nine patient requests when using the
transactionin a batch mode (See the Exceeding The Number of Patient Requests section
below for the exception). In a batch mode, it is possible to have patient requests in both
the subscriber and dependent levels (e.g. subscriber and spouse). In a batch mode it is
also possible to have more than one dependent patient requests (e.g. twins). In the case
where there are patient requests at both the subscriber and dependent levels or for
multiple dependents, each patient request counts as one patient request toward the
maximum number of ninety-nine patient requests (See Section 1.4.2 Patient Request
subsection for additional information). The 271 response can only contain eligibility and
benefit information for the patient(s) identified in the 270 request unless the 270 request
contained a value of "FAM" in 2100C EQ03 and this level of functionality is supported
by the Information Source.

Real Time
Transactions that are used in a real time mode typically are those that require an
immediate response. In a real time mode, the sender sends a request transaction to the
receiver, either directly or through a clearinghouse (switch), and remains connected
while the receiver processes the transaction and returns a response transaction to the
original sender. Typically, response times range from a few seconds to around thirty
seconds, and should not exceed one minute.

Important: When in real time mode, the receiver must send a response of either the 271
response transaction, a 999 Implementation Acknowledgment, or a TA1 segment (for
details on the TA1 segment, see Section B.1.1.5.1 - Interchange Acknowledgment, TA1).

If the transaction set is to be used in a real time mode, the Information Receiver sends
the 270 transaction through some means of telecommunication (e.g. Async., TCP/IP,
LU6.2, etc.) to the Information Source (typically through a clearinghouse - see Sections
1.4.13.2 and 1.4.13.3) and remains connected while the Information Source processes
the transaction and returns a 271 to the Information Receiver. It is required that the 270
transaction contain only one patient request when using the transaction in a real time
mode (See the Exceeding The Number of Patient Requests section below for the
exception). One patient is defined as either, one subscriber loop if the member is the
patient, or one dependent loop if the dependent is the patient (See Section 1.4.2 Patient
for additional information). The 271 response can only contain eligibility and benefit
information for the patient(s) identified in the 270 request unless the 270 request contained

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a value of "FAM" in 2100C EQ03 and this level of functionality is supported by the
Information Source.

Exceeding The Number of Patient Requests

Although it is not recommended, if the number of patients is to be greater than one for
real time mode or greater than ninety-nine for batch mode, the trading partners (the
Information Source, the Information Receiver and the clearinghouse the transaction is
routed through, if there is one involved) must all agree to exceed the number of
recommended patient requests and agree to a reasonable limit.

In the event the Information Receiver exceeds the maximum number of patient requests
allowed, two possible scenarios arise. First, if the processor of the transaction (either
the clearinghouse or the Information Source) detects the maximum has been exceeded,
a 271 with a AAA segment with element AAA03 containing a code value "04" (Authorized
Quantity Exceeded) will be issued. If this has been detected by a clearinghouse, use
the AAA segment in the Information Source Level (Loop 2000A). If this has been detected
by an Information Source, use the AAA segment in the Information Source Name loop
(Loop 2100A). Second, the processor's system may actually fail, in which case it may
not be possible to send any message back and trading partners should be aware of this
possibility.

If trading partners are going to engage in both real time and batch eligibility, it is
recommended that they identify the method they are using. One suggested way of
identifying this is by using different identifiers for real time and batch in GS02 (Application
Sender's Code) for the 270 transaction. A second suggested way is to add an extra letter
to the identifier in GS02 (Application Sender's Code) for the 270 transaction, such as
"B" for batch and "R" for real time. Regardless of the methodology used, this will avoid
the problems associated with batch eligibility transactions getting into a real time
processing environment and vice versa.

1.4.4 Supported Business Functions

The 270 transaction set is used to inquire about health care eligibility or benefit information
associated with a subscriber or dependent under the subscriber's payer and group. The
specific information detail requirements and any type of health care eligibility, benefit
inquiry or reply message is established by the business relationship between the
transaction set's submitter and recipient organization. The detail of the health care
eligibility or benefit information being requested by the inquiry submitter from the
information source organization is identified in the Eligibility or Benefit Inquiry (EQ) data
segment. To complete the detail of the eligibility request message, the submitter may

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send additional data segment information within the 270 transaction sets at the subscriber
and dependent levels.

An example of the overall structure of the 270 transaction set when used in a batch
environment is:

Information Source (Loop 2000A)

Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Subscriber (Loop 2000C)
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
Eligibility or Benefit Inquiry
Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Information Source (Loop 2000A)
Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
The corresponding 271 response follows the same structure displayed above, with the
Eligibility or Benefit Information replacing the Eligibility or Benefit Inquiry.

Requesting Information (270)

The following examples illustrate the business functions that the 270 supports. The
transaction set is not limited to these examples.

General Request Example

Submitter Type Payer/Plan Benefits Requested

All Provider Types All Medical/Surgical Benefits and

Coverage Conditions

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Categorical Request Example

Submitter Type Payer/Plan Benefits Requested

Specific Provider type All Benefits Pertinent to Provider Type

Specific Request Examples

Submitter Type Payer/Plan Benefits Requested

Ambulatory Surgery Center Hernia Repair

D.M.E Wheelchair Rental

Dentist Bonding

Free Standing Lab Diagnostic Lab Service

Home Health Nursing Visits

Hospital Pre-Admission Testing

Hospital Detoxification Services

Hospital Psychiatric Treatment

Hospital O.P. Surgery

Nursing Home Physical Therapy Services

Other Allied Health Providers Occupational Therapy

Pharmacy Prescription Drugs

Physician Well Baby Coverage

Physician Hospital Visits

Reply Information (271)

The eligibility or benefit reply information from the information source organization (i.e.,
payer or employer) is contained in the 271 in an Eligibility or Benefit Information (EB)
data segment. The information source can also return other information about eligibility
and benefits based on its business agreement with the inquiry submitter and available
information that it may be able to provide.

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The content of the Health Care Coverage, Eligibility, and Benefit Information transaction
set varies, depending on the level of data made available by the information source
organization.

Note to receivers of 271 transactions: Due to the varying level of detail that can be
returned in the 271, it is necessary to design your system to receive all of the data
segments and data elements identified as used or situational, and account for the number
of times a data segment can repeat.

General Inquiry

• eligibility status (i.e., active or not active in the plan)

• maximum benefits (policy limits)
• exclusions
• in-plan/out-of-plan benefits
• C.O.B information
• deductible
• co-pays

Specific Inquiry

• procedure coverage dates

• procedure coverage maximum amount(s) allowed
• deductible amount(s)
• remaining deductible amount(s)
• co-insurance amount(s)
• co-pay amount(s)
• coverage limitation percentage
• patient responsibility amount(s)
• non-covered amount(s)

The Health Care Eligibility transaction sets are designed to satisfy the needs of a simple
eligibility status inquiry (is the subscriber/dependent eligible?) or a request for more
complex benefit amounts, co-insurance, co-pays, deductibles, exclusions, and limitations
related to a specific procedure. To support this broad range of health care eligibility or
benefit inquiry needs, the transaction sets can be viewed as a cone of information

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requirements and responses to support the submitting and receiving organizations'

business needs.

As more complex health care eligibility or benefit information is requested from the
recipient or organization, the 270 transaction set submitter may need to supply more
detailed information in the request, and the recipient may be expected to return more
information in the 271 transaction set reply (See Figure 1.1 - Information Requirements).
The specific information detail requirements and any type of health care eligibility or
benefit inquiry or reply message is established by the business relationship between the
transaction sets submitter and recipient organization.

Figure 1.1 - Information Requirements

1.4.5 Unsupported Business Functions

The following business functions are not intended to be supported under the 270/271
transaction sets:

• medical services reservations

• authorization requirements
• certification requirements
• utilization management/review requirements

These functions are supported by the Health Care Services Review (ASC X12 278)
transaction set developed and supported by X12N/TG2/WG10, the Health Care Services
Review WG.

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1.4.6 Information Linkage

1.4.6.1 Real Time Linkage
The 270 request transaction has several methods of providing linkage to the 271 response
transaction when the transaction is being processed in Real Time (see
Section 1.4.3 - Batch and Real Time). Values returned in the 271 response transaction
must be returned exactly as submitted in the corresponding 270 request transaction.

Information Receiver

• BHT03 - Submitter Transaction Identifier. This is used to identify the transaction at a

high level. This is particularly useful in reconciling 271 reject transactions that may not
contain all of the HL Loops. This information is required for the information receiver if
using the transaction in Real Time and the receiver of the 270 transaction (whether it
is a clearinghouse or information source) must return it in the 271 BHT03.
• TRN segments in either Loop 2000C or Loop 2000D, whichever is the patient. The
information receiver may create one occurrence of the TRN segment at the lower of
these levels.These segments are optional for the information receiver, however if the
information source receives them, they must be returned in the 271 response
transaction unless a AAA is generated in 2000A, 2100A or 2100B.
• Patient Account Number. A patient account number may be entered in REF02 of a
REF segment (with REF01 being EJ) in either Loop 2100C or Loop 2100D, whichever
is the patient. This information is optional for the information receiver, however if the
information source receives the patient account number, they must return it in the 271
response transaction unless a AAA is generated in 2000A, 2100A or 2100B.

Information Source

• TRN segments in the 271 response transaction in either Loop 2000C or Loop 2000D,
whichever is the patient. The information source may create one occurrence of the
TRN segment at the lower of these levels. This segment is optional for the information
source, however, this gives the information source a mechanism to pass a transaction
reference number to the information receiver to use if there is a need to follow up on
the transaction.

Clearinghouse

• BHT03 - Submitter Transaction Identifier. This is used to identify the transaction at a

high level. This is particularly useful in reconciling 271 reject transactions that may not

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contain all of the HL Loops. This information is required for the clearinghouse if using
the transaction in Real Time and the receiver of the 270 transaction (whether it is a
clearinghouse or information source) must return it in the 271 BHT03.
• TRN segments in either Loop 2000C or Loop 2000D, whichever is the patient. A
clearinghouse may create one occurrence of the TRN segment at the lower of these
levels. These segments are optional for a clearinghouse however if the information
source receives them, they must be returned in the 271 response transaction unless
a AAA is generated in 2000A, 2100A or 2100B. In the event that the 270 transaction
passes through more than one clearinghouse, the second (and subsequent)
clearinghouse may choose one of the following options. Option One: If the second or
subsequent clearinghouse needs to assign their own TRN segment they may replace
the received TRN segment belonging to the sending clearinghouse with their own TRN
segment. Upon returning a 271 response to the sending clearinghouse, they must
remove their TRN segment and replace it with the sending clearinghouses TRN
segment. Identification of whose TRN segment is whose can be accomplished by
utilizing TRN03, which is required for clearinghouses. If the clearinghouse intends on
returning their TRN segment in the 271 response to the information receiver, they must
convert the value in TRN01 to "1". Option Two: If the second or subsequent
clearinghouse does not need to assign their own TRN segment, they should merely
pass all TRN segments received in the 270 transaction and pass all TRN segments
received in the 271 response transaction.
NOTE: If the Information Source determines that the patient was submitted as a
subscriber but is actually a dependent, the TRN segment(s) submitted in the 2000C
loop, along with the patient information will be moved to the 2000D loop. If the
Information Source determines that the patient was submitted as a dependent but is
actually a subscriber, the TRN segment(s) submitted in the 2000D loop, along with
the patient information will be moved to the 2000C loop. See Section 1.4.2 - Basic
Concepts for additional information.

1.4.6.2 Batch Linkage

Given the nature of batch processing which may or may not respond to each of the
requests in the same batch response, the 270 request transaction has fewer methods
of providing linkage to the 271 response transaction when the transactions are being
processed in Batch (see Section 1.4.3 - Batch and Real Time). Values returned in the
271 response transaction must be returned exactly as submitted in the corresponding
270 request transaction.

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Information Receiver

• BHT03 - Submitter Transaction Identifier. This is used to identify the transaction at a

high level. This is particularly useful in reconciling 271 reject transactions that may not
contain all of the HL Loops. This information may be sent at the information receiver's
discretion if using the transaction in a Batch mode. Due to the nature of batch
transaction processing, the receiver of the 270 transaction (whether it is a clearinghouse
or information source) may or may not be able to return the 270 BHT03 value in the
271 BHT03.
• TRN segments in either Loop 2000C or Loop 2000D, whichever is the patient. The
information receiver may create one occurrence of the TRN segment at the lower of
these levels. These segments are optional for the information receiver, however if the
information source receives them, they must be returned in the 271 response
transaction unless a AAA is generated in 2000A, 2100A or 2100B.
• Patient Account Number. A patient account number may be entered in REF02 of a
REF segment (with REF01 being EJ) in either Loop 2100C or Loop 2100D, whichever
is the patient. This information is optional for the information receiver, however if the
information source receives the patient account number, they must return it in the 271
response transaction unless a AAA is generated in 2000A, 2100A or 2100B.

Information Source

• TRN segments in the 271 response transaction in either Loop 2000C or Loop 2000D,
whichever is the patient. The information source may create one occurrence of the
TRN segment at the lower of these levels. This segment is optional for the information
source, however, this gives the information source a mechanism to pass a transaction
reference number to the information receiver to use if there is a need to follow up on
the transaction.

NOTE: If the Information Source determines that the patient was submitted as a
subscriber but is actually a dependent, the TRN segment(s) submitted in the 2000C
loop, along with the patient information will be moved to the 2000D loop. If the
Information Source determines that the patient was submitted as a dependent but is
actually a subscriber, the TRN segment(s) submitted in the 2000D loop, along with
the patient information will be moved to the 2000C loop. See Section 1.4.2 for additional
information.

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1.4.7 Implementation-Compliant Use of the 270/271

Transaction Set
The ANSI ASC X12N Implementation Guideline for the Health Care Eligibility Benefit
Inquiry and Response 270/271 transaction set contains a super set of data segments,
elements and codes which represent its full functionality. This super set covers a great
number of business scenarios and does not necessarily represent the business needs
of an individual provider, payer or other trading partner involved in the use of the 270/271.
The super set identifies the framework an information source (typically a payer), can
utilize. This Implementation Guide also identifies the minimum an information source or
clearinghouse is required to support in order to offer an implementation-compliant 270/271
transaction. Identification of the person being inquired about can be found in
Section 1.4.8 - Search Options.

The 271 transaction is designed to report a great deal more than "Yes, the patient is
eligible today". Some of the items that can be returned if the conditions apply are:
Co-payment, Co-insurance, Deductible amounts, Plan Beginning and Ending Dates,
allowing for dates other than the current date and information about the Primary Care
Provider. Additionally, specific service types and their related information can also be
returned.

The 271 response can get as elaborate as identifying what days of the week a member
can have a service performed and where, the number of benefits they are allowed to
have and how many of them they have remaining, whether the benefit conditions apply
to "in" or "out" of network, etc. Anything that is identified as situational in the 271 could
possibly be returned, this is the super set.The Implementation Guide states that receivers
of the 271 transaction need to "design their system to receive all of the data segments
and data elements identified as used or situational, and account for the number of times
a data segment can repeat." This allows the information source the flexibility to send
back relevant information without the receiver having to reprogram their system for each
different information source.

Just as the 271 response can be as elaborate as the information source wishes to return,
the 270 request can also be very explicit. A provider could send a 270 request to ask
whether a particular patient is eligible for a particular procedure with a particular diagnosis
code, identify who the provider of the service will be and even to identify when and where
the requested service will be performed. An information source is not required to generate
an explicit response to an explicit request if their system is not capable of handling such
requests. However, the more information an information source can provide the
information receiver regarding specific questions, the more both parties will be able to

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reduce phone calls and long interruptions. The information source is required to at least
respond with the minimum compliant response as noted in this section and may not
reject the transaction merely because they cannot process an explicit request. Willing
trading partners are allowed to use any portion or all of the 270/271 super set; so long
as they support the minimum data set, but are not allowed to add to or change it in order
to remain compliant with this Implementation Guide.

1.4.7.1 Minimum Requirements For Implementation Guide

Compliance
270
An information source must support a generic request for Eligibility.This is accomplished
by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in the "EQ"
loop of the transaction. See section 1.4.7.2 for additional Service Type Code support
information.

271
Unlike the 004010X092 270/271 Health Care Eligibility Benefit Request Response
Implementation Guide which stated "An information source must respond with either an
acknowledgment that the individual has active or inactive coverage or that the individual
was not found in their system", the mandated response now has some additional
requirements.

If the individual is located in the information source's system, the following must be
returned:

1. If the individual has active coverage, the 346 Plan Begin date must be returned in
2100C/D DTP unless multiple plans apply to the individual or multiple plan periods
apply, which must then be returned in the 2110C/D DTP. May alternately return a
291 Plan range of dates if known.
If benefit dates are different from the 2100C/D Plan or Plan Begin date, either 348
Benefit Begin date or 292 Benefit date must be returned in the 2110C/D loop with
the associated EB03 benefit.
NOTE: Plan dates represent coverage dates in the plan or program that is being
represented in the response. This date does not have to represent the historical
beginning of eligibility for the plan, only the most recent plan date(s). For example,
Medicaid may only report plan dates in one month periods of time.

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2. For each plan for which the individual has active or inactive coverage, a 2110C/D
loop is required with EB01 Status = 1, 2, 3, 4, 5, 6, 7 or 8 with 2110C/D EB03 Service
Type Code = 30 (Health Benefit Plan Coverage) and Plan Name in EB05 if one exists.
3. If the patient is the subscriber, demographic information (Subscriber's First and Last
Name, Subscriber's Date of Birth and Member ID) and any other information (e.g.
Address) required to identify the individual on subsequent EDI transactions (e.g. 837
Health Care Claim or 278 Health Care Services Review - Request for Review) must
be returned.
4. If the patient is a dependent, demographic information (Subscriber's Member ID,
Dependent's First and Last Name, and Dependent's Date of Birth) and any other
information (e.g. Address) required to identify the individual on subsequent EDI
transactions (e.g. 837 Health Care Claim or 278 Health Care Services Review -
Request for Review) must be returned.
5. Primary Care Provider in 2120C/D if applicable
6. Other payers or plans if known in 2120C/D. (Note: Do not return details of coverage
or benefits associated with other payers or plans, the Information Receiver should
initiate a separate 270 request to the other payer or plan to determine the level of
coverage.)
7. The information source is also required to return information from any of the following
segments supplied in the 270 request that was used to determine the 271 response:
2100B N3 or N4
2100B, 2100C or 2100D PRV
2100C or 2100D HI
2110C or 2110D loop (all segments)
Examples of such information are, but not limited to, service type codes, procedure
codes, diagnosis codes, facility type codes, dates and identification numbers.
NOTE: If the information from the above listed segments in the 270 request was not
used to determine the 271 response, that information from the 270 request must not
be returned. In this instance, the information source may return this information from
what they have on file.

8. If an information source receives a Service Type Code "30" submitted in the 270
EQ01 or a Service Type Code that they do not support, the following 2110C/D EB03
values must also be returned if they are a covered benefit category at a plan level.

1 - Medical Care
33 - Chiropractic

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35 - Dental Care
47 - Hospital
86 - Emergency Services
88 - Pharmacy
98 - Professional (Physician) Visit - Office
AL - Vision (Optometry)
MH - Mental Health
UC - Urgent Care
The above codes must have the appropriate EB01 = 1-5. If it is not a covered benefit,
the code must not be returned. The repetition function of EB03 must be used if only
reporting the Active Status or if Patient Responsibility is the same across multiple
benefits. If any of the above benefits are associated with an other entity (e.g. carve
out) the information must be returned in 2120C/D if known.

If the information source's plan does not fall into any of the 10 Service Type Codes
listed above, the plan must return the Active Status information and whatever additional
appropriate service type code does define the benefit. If no service type code exists,
the plan may return either the appropriate procedure code(s) in EB13 or a description
in MSG01. EB03 and EB13 cannot both be used in the same EB segment. If an
appropriate procedure code is available for use in EB13, MSG01 must not be used.

9. If an information source supports an explicit request for Service Type Codes "1", "33",
"35", "47", "86", "88", "98", "AL", "MH" or "UC" submitted in the 270 EQ01, they are
required to return the items identified in items 1 to 6, but are only required to return
benefits associated with the submitted Service Type code and are not required to
return any of the other service type codes identified in the generic response. If the
service type code is supported, however the benefit is not covered, the appropriate
response would be EB01 = "I", Non-Covered.
Additional covered Service Type Codes may be returned at the information source's
discretion; however their absence does not imply that they are not covered.

10. The response will be for the date the transaction is processed, unless a specific Plan
date (prior, current or future) was used from the DTP of the 270. For example, prior
dates are needed for Medicaid inquiries, so providers can determine if a patient's
application for state medical assistance has been processed, claims can not be
submitted until the benefit has been activated, which can be retroactive for qualifying
recipients.

11. When an organization receives an eligibility request and can locate the patient,
however if they are not the true information source (such as labor funds), return an

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EB01 = "U" (Contact Following Entity for Eligibility or Benefit Information) with the
true Information Source's contact information in the 2120 loop. In this case, neither
a status of Active or Inactive, nor any of the other required items from this section
are required to be returned.

12. Information Sources are not limited to returning the 10 Service Type Codes identified
in 1.4.7.1 Item 8.

1.4.7.2 Recommended Additional Support

In addition to the mandated response components, it is highly recommended that the
information source returns any known patient financial responsibility (e.g. Co-insurance,
co-payment, deductible, etc) for benefits described. See Section 1.4.9 - Patient
Responsibility for additional information.

Each of the 10 mandated Service Type Codes identified in Section 1.4.7.1 item 8 ("1",
"33", "35", "47", "86", "88", "98", "AL", "MH" or "UC") can be broken into their components.
This level of support can be used if an information receiver sends a 270 request with
one of the 10 service type codes returned in a mandated 271 response. This will allow
the information receiver to receive more detailed relevant information.

The following are some of the components that make up each of the 10 mandated service
type codes. This is intended as guidance to show some of the service type codes that
could be returned if one of the 10 listed service type codes is sent in a 270 transaction
and not an all inclusive list. If this functionality is supported, the information source must
still return all of the mandated components outlined above. This is not mandated, and
if the information source cannot support this explicit level of request, they are to respond
as if a 270 were received with an EQ01 = 30.

Codes 33 - Chiropractic, 86 - Emergency Services and UC - Urgent Care may have

related components; however, those may be determined at the information sources
discretion.

Service Type Code Components

1 - Medical Care
2 - Surgical
3 - Consultation
42 - Home Health Care
45 - Hospice
54 - Long Term Care

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69 - Maternity
73 - Diagnostic Medical
76 - Dialysis
83 - Infertility
AG - Skilled Nursing Care
BT - Gynecological
BU - Obstetrical
BV - Obstetrical/Gynecological
DM - Durable Medical Equipment
35 - Dental
23 - Diagnostic Dental
24 - Periodontics
25 - Restorative
26 - Endodontics
27 - Maxillofacial Prosthetics
28 - Adjunctive Dental Services
36 - Dental Crowns
37 - Dental Accident
38 - Orthodontics
39 - Prosthodontics
40 - Oral Surgery
41 - Routine (Preventive) Dental
47 - Hospital
48 - Hospital Inpatient
49 - Hospital - Room and Board
50 - Hospital - Outpatient
51 - Hospital - Emergency Accident
52 - Hospital - Emergency Medical
53 - Hospital - Ambulatory Surgical
88 - Pharmacy
89 - Free Standing Prescription Drug
90 - Mail Order Prescription Drug
91 - Brand Name Prescription Drug
92 - Generic Prescription Drug
BW - Mail Order Prescription Drug: Brand Name
BX - Mail Order Prescription Drug: Generic
GF - Generic Prescription Drug - Formulary

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GN - Generic Prescription Drug - Non-Formulary

98 - Professional (Physician) Visit - Office
BY - Physician Visit - Office: Sick
BZ - Physician Visit - Office: Well
MH - Mental Health
67 - Smoking Cessation
A4 - Psychiatric
A5 - Psychiatric - Room and Board
A6 - Psychotherapy
A7 - Psychiatric - Inpatient
A8 - Psychiatric - Outpatient
AI - Substance Abuse
AJ - Alcoholism
AK - Drug Addiction

1.4.7.3 Streamlining Responses

The 271 transaction contains an extensive amount of flexibility and ability to provide
valuable data. As more data is supplied in the 271, the information sources should
consider the advantage of streamlining the data to specifically fit the person whose
benefits are being requested in the 270. Not only will this clarify the coverage for the
information receiver but may reduce the length of the transaction. When an information
source is returning additional information, above and beyond the requirements of this
section, the following recommendations should be taken into consideration.

1.4.7.4 Person Specific Benefit Responses

Many benefits are associated with the gender or age of a patient. It is encouraged that
benefits supplied in the 271 are matched with the appropriate age or gender of the patient
in the 270 request. For example, maternity benefits would only be sent on a female
patient. Also, only the benefit matching the age of the patient should be sent.

1.4.7.5 Patient History Benefit Responses

There are different levels of benefits based on the number of services provided, the date
the patient was last seen or other service related items. The information source may
wish to consider providing the information receiver with the exact benefit level in effect
at the time the request was made. The actual benefit applied could be different due to
the timing of the request with respect to the consideration or payment of other services
not known at the time of the eligibility request.

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1.4.8 Search Options

Unlike many other X12 transactions, the 270 transaction has the built in flexibility of
allowing a user to enter whatever patient information they have on hand to identify them
to an information source. Obviously the more information that can be provided, the more
likely the information source will find a match in their system. The developers of this
implementation guide have defined a maximum data set that an information source may
require and identified further elements the information source may use if they are
provided. The maximum data set the Information Source may require is referred to
throughout this Implementation Guide as the Primary Search Option. As noted in
Section 1.4.2 - Basic Concepts, the patient may be identified in either loop 2100C or
2100D.

In most cases, the patient's ID card would identify if the person is uniquely identifiable
to the payer or must be associated with the subscriber. For example, if the patient is a
dependent, they are typically listed on the subscriber's ID card as dependents and do
not receive their own ID card. If there is confusion as to whether the patient is a subscriber
or a dependent, the transaction should be submitted with the patient as the subscriber.

1.4.8.1 Required Primary Search Options

If the patient is the subscriber, the maximum data elements that can be required by an
information source to identify a patient in loop 2100C are:

Patient is Subscriber
Patient's Member ID (or the HIPAA Unique Patient Identifier if mandated for use)
Patient's First Name
Patient's Last Name
Patient's Date of Birth
If all four of these elements are present the information source must generate a response
if the patient is in their database. All information sources are required to support the
above search option.

When the patient is the subscriber, it is recommended that an Information Source use
all four of these elements in locating the patient in their database; however Information
Receivers should be aware that the Information Source might not have used all four of
these elements.

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Patient is Dependent
If the patient is a dependent of a subscriber, the maximum data elements that can be
required by an information source to identify a patient in loop 2100C and 2100D are:

Loop 2100C
Subscriber's Member ID
Loop 2100D
Patient's First Name
Patient's Last Name
Patient's Date of Birth
If all four of these elements are present the information source must generate a response
if the patient is in their database. All information sources are required to support the
above search option if their system does not have unique Member Identifiers assigned
to dependents.

When the patient is the dependent, it is recommended that an Information Source use
all four of these elements in locating the patient in their database; however Information
Receivers should be aware that the Information Source might not have used all four of
these elements.

1.4.8.2 Required Alternate Search Options

In some instances all four pieces of information from the Primary Search Option are not
available, such as in an emergency situation, or there are differences between the
identifying information for the individual that the provider has and what the information
source has (such as misspelled name). To accommodate these types of situations, and
to provide a set of standardized alternate search options, the developers of this
Implementation Guide have defined four alternate search options that an Information
Source is required to support in addition to the Primary Search Option. The maximum
data set the Information Source may require for these alternate search options is referred
to throughout this Implementation Guide as the Required Alternate Search Options. The
order of the search options does not imply that any search option should be used over
any other, since they are to be used when one of the pieces of information from the
Primary Search Option is missing.

Patient is Subscriber
If the patient is the subscriber, the maximum data elements that can be required by an
information source for a Required Alternate Search Option to identify a patient in loop
2100C are:

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Member ID/Date of Birth/Last Name Search Option

Loop 2100C
Patient's Member ID Number
Patient's Date of Birth
Patient's Last Name

Member ID/Name Search Option

Loop 2100C
Patient's Member ID Number
Patient's First Name
Patient's Last Name

Patient is Dependent
If the patient is a dependent of a subscriber, the maximum data elements that can be
required by an information source for a Required Alternate Search Option to identify a
patient in loop 2100C and 2100D are:

Member ID/Date of Birth/Last Name Search Option

Loop 2100C
Subscriber's Member ID Number
Loop 2100D
Patient's Date of Birth
Patient's Last Name

Member ID/Name Search Option

Loop 2100C
Subscriber's Member ID Number
Loop 2100D
Patient's First Name
Patient's Last Name
If all of the elements for one of the Required Alternate Search Options are present, the
Information Source is required to search for the patient in their system and if a unique
match for an individual can be made, the Information Source is required to return the
appropriate eligibility response as outlined in Section 1.4.7 - Implementation-Compliant
Use of the 270/271 Transaction Set.

If an Information Source is unable to identify a unique individual in their system (more

than one individual matches the information from the Required Alternate Search Option),

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the Information Source is required to reject the transaction and identify in the 2100C or
2100D AAA segment the additional information from the Primary Search Option that is
needed to identify a unique individual in the Information Source's system.

Search Options and Error Handling Matrix

This table identifies the Required Alternate Search Option used and how to respond
when there is a unique individual or multiple individuals found in the Information Source's
system. When multiple individuals are found, the 271 response must contain the error
code indicating which item is needed from the Primary Search Option to eliminate the
multiple matches and ensure the correct individual is returned. This table is for 270
transactions that do not have errors for invalid Member ID (MID), Name (First/Last) or
Date of Birth (DOB).

Search Patient is Patient is Match 271 Error

Option Subscriber Dependent Results Returned Code

MID/DOB/ Yes No Unique 2110C EB None

Last Name Multiple 2100C AAA AAA03 = 73

Name/MID Yes No Unique 2110C EB None

Multiple 2100C AAA AAA03 = 58

MID/DOB/ No Yes Unique 2110D EB None

Last Name Multiple 2100D AAA AAA03 = 65

Name/MID No Yes Unique 2110D EB None

Multiple 2100D AAA AAA03 = 58

1.4.8.3 Name/Date of Birth Search Option

In some instances all pieces of information from the Primary Search Option or one of
the Required Alternate Search Options are not available, such as in an emergency
situation or if the patient has forgotten to bring their identification card. To accommodate
these types of situations, and to provide guidance on standardized alternate search
options, the developers of this Implementation Guide have defined a Name/Date of Birth
Search Option that an Information Source may, at their discretion but are not required
to, support in addition to the Primary Search Option and Required Alternate Search
Options.

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Patient is Subscriber
If the patient is the subscriber, the maximum data elements that can be required by an
information source for a Name/Date of Birth Search Option to identify a patient in loop
2100C are:

Name/Date of Birth Search Option

Patient's First Name
Patient's Last Name
Patient's Date of Birth

Patient is Dependent
If the patient is a dependent of a subscriber, the maximum data elements that can be
required by an information source for a Name/Date of Birth Search Option to identify a
patient in loop 2100D are:

Name/Date of Birth Search Option

Loop 2100D
Patient's First Name
Patient's Last Name
Patient's Date of Birth

NOTE: When using the Patient is Dependent variant of the Name/Date of Birth Search
Option, a 2000C and 2100C loop must be created with the dependent information sent
in the 2100D loop.

Search Options and Error Handling Matrix

This table identifies the Name/Date of Birth Search Option used and how to respond
when there is a unique individual or multiple individuals found in the Information Source's
system. When multiple individuals are found, the 271 response must contain the error
code indicating which item is needed from the Primary Search Option to eliminate the
multiple matches and ensure the correct individual is returned. This table is for 270
transactions that do not have errors for invalid Name (First/Last) or Date of Birth (DOB).

Patient is Dependent is Match 271 Error

Subscriber Patient Results Returned Code

Yes No Single 2110C EB None

Yes No Multiple 2100C AAA AAA03 = 72

No Yes Single 2110D EB None

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Patient is Dependent is Match 271 Error

Subscriber Patient Results Returned Code

No Yes Multiple 2100C AAA AAA03 = 72

Minimum Response for a unique match

Section 1.4.7.1 identifies the Minimum Requirements for Implementation Compliance
for a 271 response. If the Name/Date of Birth Search Option was utilized, the Information
Source is not required to return all of the information outlined in section 1.4.7.1 with the
exception of the following:

1. For each plan for which the individual has coverage, a 2110C/D loop is required with
EB01 Status = 1, 2, 3, 4, 5, 6, 7 or 8 with 2110C/D EB03 Service Type Code = 30
(Health Benefit Plan Coverage) and Plan Name in EB05 if one exists.

Recommended Additional Response Information

In addition to the above, Information Sources are encouraged to return the following at
their discretion:

1. Any or all of the information contained in Section 1.4.7.1 (including but not limited to
the Member ID number, Patient's Address and any other information that might help
the provider ensure that the person returned is the patient for which the provider
requested eligibility).

2. If the Member ID is not returned, a 2110C/D with EB01 = "U" (Contact the following
Entity for Eligibility or Benefit Information) and a customer support phone number in
2120C/D.

Provider Validation
When the Name/Date of Birth Search Option is used, the provider must use reasonable
effort in comparing the information returned in the 271 response to information they have
available (e.g. demographic information in their system or directly asking the patient) to
validate the information returned on the 271 is for correct patient.

1.4.8.4 Member ID Number/Date of Birth Search Option

In some instances all pieces of information from the Primary Search Option or one of
the Required Alternate Search Options are not available, or there are differences between
the identifying information for the individual that the provider has and what the information
source has (such as misspelled name). To accommodate these types of situations, and

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to provide guidance on standardized alternate search options, the developers of this

Implementation Guide have defined a Member ID/Date of Birth Search Option that an
Information Source may, at their discretion but are not required to, support in addition
to the Primary Search Option and Required Alternate Search Options.

Patient is Subscriber
If the patient is the subscriber, the maximum data elements that can be required by an
information source for a Member ID/Date of Birth Search Option to identify a patient in
loop 2100C are:

Member ID/Date of Birth Search Option

Patient's Member ID Number
Patient's Date of Birth

Patient is Dependent
If the patient is a dependent of a subscriber, the maximum data elements that an be
required by an information source for a Member ID/Date of Birth Search Option to identify
a patient in loop 2100C and 2100D are:

Member ID/Date of Birth Search Option

Loop 2100C
Subscriber's Member ID Number

Loop 2100D
Patient's Date of Birth

Search Options and Error Handling Matrix

This table identifies the Member ID/Date of Birth Search Option used and how to respond
when there is a unique individual or multiple individuals found in the Information Source's
system. When multiple individuals are found, the 271 response must contain the error
code indicating which item is needed from the Primary Search Option to eliminate the
multiple matches and ensure the correct individual is returned. This table is for 270
transactions that do not have errors for invalid Member ID Number or Date of Birth (DOB).

Patient is Patient is Match 271 Error

Subscriber Dependent Results Returned Code

Yes No Single 2110C EB None

Yes No Multiple 2100C AAA AAA03 = 73

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Patient is Patient is Match 271 Error

Subscriber Dependent Results Returned Code

No Yes Single 2110D EB None

No Yes Multiple 2100D AAA AAA03 = 65

Minimum Response for a unique match

Section 1.4.7.1 identifies the Minimum Requirements for Implementation Compliance
for a 271 response. If the Member ID/Date of Birth Search Option was utilized, the
Information Source is not required to return all of the information outlined in section
1.4.7.1 with the exception of the following:

1. For each plan for which the individual has coverage, a 2110C/D loop is required with
EB01 Status = 1, 2, 3, 4, 5, 6, 7 or 8 with 2110C/D EB03 Service Type Code = 30
(Health Benefit Plan Coverage) and Plan Name in EB05 if one exists.

Recommended Additional Response Information

In addition to the above, Information Sources are encouraged to return the following at
their discretion:

1. Any or all of the information contained in Section 1.4.7.1 (including but not limited to
the Patient's Name, Patient's Address and any other information that might help the
provider ensure that the person returned is the patient for which the provider requested
eligibility).

2. If the Patient's Name is not returned, a 2110C/D with EB01 = "U" (Contact the following
Entity for Eligibility or Benefit Information) and a customer support phone number in
2120C/D.

Provider Validation
When the Member ID Number/Date of Birth Search Option is used, the provider must
use reasonable effort in comparing the information returned in the 271 response to
information they have available (e.g. demographic information in their system or directly
asking the patient) to validate the information returned on the 271 is for correct patient.

1.4.8.5 Additional Alternate Search Options

Information sources are encouraged to support additional alternate search options to
assist in locating a patient in the absence of all four pieces of information from the Primary

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Search Option or when one of the Required Alternate Search Options does not locate
a unique match for an individual in their system. Other alternate search options can
utilize any of the data elements in the 2100C loop for a subscriber or the 2100D loop for
a dependent such as Social Security Number, Address or Gender.

The information source should attempt to look up the patient if there is a reasonable
amount of information present. An information source may outline additional search
options available in their trading partner agreement; however under no circumstances
may they require the use of a search option that differs from the ones outlined in the
Required Primary Search Options section above.

NOTE
The information source is required to return all information used from the 270 transaction
to locate the patient.

1.4.8.6 Insufficient Identifying Elements

In the event that insufficient identifying elements are sent to the information source, the
information source will return a 271 identifying the missing data elements in a AAA
segment.

1.4.8.7 Multiple Matches

In the event that multiple matches are found in the information source's database (this
should be due only to utilizing a search option other than the required search option),
the information source must not return all the matches found. In this case, the information
source must return a 271 AAA segment, identifying the missing data elements necessary
to provide an exact match.

1.4.9 Patient Responsibility

Health Plans have many different ways of identifying the patient's monetary responsibility
when services are rendered. Depending on the type of plan the patient is enrolled in
such as an HMO, PPO or traditional indemnity plan, the types of patient responsibility
will vary. The most common of these are Co-Payment, Co-Insurance and Deductible.
Loops 2110C and 2110D use the EB01 Eligibility or Benefit Information Code to begin
the loop establishing what the patient responsibility is. For each of the EB01 code values
that represent either a dollar or percentage based patient responsibility, codes and their
definitions have been identified and instructions on how to use them in conjunction with
this Implementation Guide are included below.

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NOTE
Some health plans may use these terms differently than identified in this Implementation
Guide, and the Implementation Guide definitions take precedence when used in
conjunction with this transaction.

Eligibility or Benefit Information Code Definitions

A - Co-Insurance:
Co-Insurance represents the patient's portion of responsibility for a benefit and is
represented as a percentage in EB08. The co-insurance percentage is typically found
in a fee for service environment and is based on a percentage of the total amount the
provider would be paid for the service(s). Since the actual amount that would be paid to
the provider may not be known until after the claim has been processed, a percentage
is used, rather than an actual dollar amount. For example, a patient may have a 20%
co-insurance for a physician office visit if the provider is in the plan the patient belongs
to or patient may have a 40% co-insurance for a physician office visit if the provider is
not in the plan the patient belongs to. The provider may calculate an estimated amount
to collect from the patient, or may wait until after the claim has been processed to collect
the actual amount from the patient (requirements may vary from plan to plan). If the
patient's portion of responsibility for a benefit is nothing, "0" is to be placed in EB08.
Negative numbers are prohibited.
B - Co-Payment
Co-Payment represents the patient's portion of responsibility for a benefit and is
represented as a dollar amount in EB07. The co-payment amount is typically a fixed
amount and is customarily collected upon receipt of service (however the requirements
may vary from plan to plan). For example, a patient may have a $10 co-payment for a
physician office visit or a $50 co-payment for an Emergency Room visit. If the patient's
portion of responsibility for a benefit is nothing, "0" is to be placed in EB07. Negative
numbers are prohibited.
C - Deductible
Deductible represents the total amount of the patient's portion of responsibility for a
benefit and is represented as a dollar amount in EB07. The deductible amount is typically
found in a fee for service environment and is based on the total amount the patient will
have to pay before their benefits begin (which may then require co-insurance or
co-payment). If the patient's portion of responsibility for a benefit is nothing, "0" is to be
placed in EB07. Negative numbers are prohibited.
G - Out of Pocket (Stop Loss)

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Out of Pocket (Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient,
up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount
typically represents the combined total amount of deductible and co-insurance payments
made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family. The Out of Pocket (Stop
Loss) amount is represented as a dollar amount in EB07. If the patient's portion of
responsibility for a benefit is nothing, "0" is to be placed in EB07. Negative numbers are
prohibited.
J - Cost Containment
Cost Containment represents the total amount of the patient's portion of responsibility
for a benefit and is represented as a dollar amount in EB07. Cost Containment is typically
found in the Medicaid environment and represents the total amount the patient will have
to pay out of their own pocket before their benefits begin (which may or may not then
require co-insurance or co-payment). If the patient's portion of responsibility for a benefit
is nothing, "0" is to be placed in EB07. Negative numbers are prohibited.
Y - Spend Down
Spend Down represents the total amount of the patient's portion of responsibility for a
benefit and is represented as a dollar amount in EB07. Spend Down is typically found
in the Medicaid environment and represents the total amount the patient will have to pay
out of their own pocket before their benefits begin (which may or may not then require
co-insurance or co-payment). If the patient's portion of responsibility for a benefit is
nothing, "0" is to be placed in EB07. Negative numbers are prohibited.

Combinations of Patient Responsibility

Many health plans will use a combination of these items to express the patient's benefit
coverage. By way of an example, the patient's deductible might be $150 for the individual
and $300 for the family, their co-insurance might be 20 percent, and their Out of Pocket
Maximum (Stop Loss) might be $1,500 for the individual and $3,000 for the family. During
a plan year, the health plan does not pay any benefit until one of the following happens:
a) the first $150 in health care expenses has been paid by the subscriber for the patient
addressed by the claim, or b) the subscriber has paid a total of $300 for covered health
care services for all the individuals covered by the subscriber's policy. After that, the
subscriber pays 20% of the covered health care expenses for the patient until that 20%
leads to $1500 in expenses (or $3000 across patients covered by the contract) then the
insurance benefits increase, typically to full coverage up to the maximum benefit.

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1.4.10 Rejected Transactions

A 271 Eligibility, Coverage or Benefit Information response transaction must contain at
least one EB (Eligibility or Benefit Information) segment or one AAA (Request Validation)
segment. This is assuming that the 270 Eligibility, Coverage or Benefit Inquiry has passed
syntax error checking without any errors and has not been identified as rejected in a
999 Implementation Acknowledgement.

The AAA Request Validation segment is used to identify why an EB Eligibility or Benefit
Information segment has not been generated or in essence, why the 270 Eligibility,
Coverage or Benefit Inquiry has been rejected. Typically an AAA segment is generated
as a result of either an error in the data being detected (e.g. Missing Subscriber ID) or
no matching information in the database (e.g. Subscriber Not Found). The difference is
subtle, but they generate different types of messages. If data is missing or invalid, it
must be corrected and a new transaction must be generated. If an entity is not found in
the database however, it could mean one of two things. The first would be that the
Information Receiver should review what was submitted to verify that it was correct and
if it was incorrect take the necessary steps to correct and resubmit the transactions. The
second would be, if it is determined that the data was correct, the entity is not associated
with the Information Source or clearinghouse processing the transaction and a definitive
answer has been generated. One other use of the AAA segment is to identify a problem
with the processing system itself (e.g. the Information Source's system is down). In this
case, validation of data may or may not have taken place, so the assumption is made
that the data is correct (AAA01 would be "Y" since it cannot point out where the error
is), but the transaction will likely have to be resent (as determined by AAA04).

There are three elements that are used in the AAA segment. AAA01 is a Yes/No indicator
(identifies if the data content was valid). AAA02 is not used. AAA03 is a Reject Reason
Code (identifies why the transaction did not generate an EB segment). AAA04 is a
Follow-up Action Code (identifies what further action should be taken).

AAA01 is used to indicate if errors were detected with the data or the transaction as a
whole. A "Y" indicates that no data errors were detected and the transaction was
processed as far as it could go. An "N" indicates that errors were detected in the data
and corrective action is needed. The reason AAA01 would have a "Y" in the event there
is a system problem is because no errors were detected in the transaction itself.

AAA03 is used to indicate why an EB segment was not generated. This is in essence
an error code.

AAA04 is used to indicate what action, if any, the Information Receiver should take.

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1.4.11 Disclaimers Within the Transactions

The developers of this Implementation Guideline strongly discourage the transmission
of a disclaimer as a part of the transaction. Any disclaimers necessary should be outlined
in the agreement between trading partners. Under no circumstances should there be
more than one disclaimer segment returned per individual response.

1.4.12 Message Segments

Under no circumstances can an information source use the MSG segment to relay
information that can be sent using codified information in existing data elements (including
combinations of multiple data elements and segments). If the information cannot be
codified, then cautionary use of the MSG segment is allowed as a short term solution.
It is highly recommended that the entity needing to use the MSG segment approach
X12N with data maintenance to solve the long term business need, so the use of the
MSG segment can be avoided for that issue.

1.4.13 Information Flows

Following are several scenarios where response transactions are exchanged by trading
partners in different environments. The roles vary from direct connections, to connecting
through communications services like VANS or other intermediaries. Requesters will
operate in a variety of application environments. The following scenarios show a variety
of environments using a hospital and a small physician's practice as role players.

1.4.13.1 Basic Information Flow

The basic flow is for a requester (usually a provider) to ask a responder (usually a payer)
about health care coverage eligibility and associated benefits. The requester is normally
asking about one individual, who may be the dependent of a health plan subscriber.
Sometimes the responder is a third party administrator, or a Utilization Review
Organization, or a self-paying employer. However, in all cases the basic flow is the same
-- a request sent and a response received.

Figure 1.2 - Basic Information Flow

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1.4.13.2 Intermediaries
A more complicated flow is from a requester (provider) to a clearinghouse service and
from the clearinghouse service to the responder (payer). The requester has an indirect
link to a variety of responders via a transaction clearinghouse service. The requester
has a dial-up, or leased line, or a private virtual circuit to the clearinghouse, and the
clearinghouse usually has a leased line to the responder. The clearinghouse may be
independent or owned by a payer.

Figure 1.3 - Intermediaries

1.4.13.3 Multiple Intermediaries

In some business relationships, the clearinghouse will provide access to all payers for
a provider, but may not have a direct connection with all payers. The clearinghouse may
have a relationship with another clearinghouse who does have a direct connection with
some payers. In this case, Clearinghouse "A" will pass the message to Clearinghouse
"B" to route the transaction to the responder.

Figure 1.4 - Multiple Intermediaries

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1.4.13.4 Multiple Responders

In some instances, the requester will query a responder, who in turn will also query a
responder for additional information. An example of this situation would be when the
first responder is a Third Party Administrator (TPA), and they in turn may query an
employer or a payer to ensure that the patient or subscriber is still actively enrolled.
When returning the second responder's transaction to the requester, the TPA may add
information to the response. Another example might be when the first responder is a
payer who knows that there may be a third party liability (TPL) payer; they might first
query the TPL before responding to the requester.

Figure 1.5 - Multiple Responders

1.4.13.5 Value Added Service Organizations

With the rising need for information exchange between many organizations within the
health care community, there are emerging service organizations that are enabling
communication for all members of the community. Because there are many different
ways to communicate with the various players in health care, service organizations will
normalize communication solutions, data requirements, and transactions formats for
their business partners. In these situations, the service organization will often need to
open the transactions to reformat them or add needed information. In some cases, these
Third Parties will perform database look-ups to determine what formats and additional
information is required. They will then direct the transactions on to the appropriate
responder or requester.

There can be other layers of complexity here, when clearinghouses might also be
involved.

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Figure 1.6 - Value Added Service Organizations

Figure 1.7 - Value Added Service Organizations with Clearinghouses

1.4.13.6 Complex Requester Environments

There are also considerations for complex requester environments for transaction routing.
Hospitals and Integrated Health Networks (IHN) are good examples of this need. The
hospital or IHN may have many systems within its enterprise or environment from which
it receives requests. It then delivers these requests to a service organization or payers.
For example, an IHN may include a hospital, a free standing clinic, a reference lab, and
an x-ray department each having its own information system, but a common interface
engine to the payers or VAN or service organization. In some cases, this interface engine
may also be performing data and communication transformations, for example taking
HL7 transactions and converting them to X12 transactions.

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Figure 1.8 - Complex Requester Environments

1.5 Business Terminology

Batch
When transactions are used in batch mode, they are typically grouped together in large
quantities and processed en-masse. Typically, the results of a transaction that is
processed in a batch mode would be completed for the next business day if it has been
received by a predetermined cut off time. See Section 1.4.3 - Batch and Real Time for
business usage of Batch transactions.

Dependent
The dependent is a person who cannot be uniquely identified to an information source
by a unique Member Identification Number, but can be identified by an information source
when associated with a subscriber. See definition of patient below for further detail. See
Section 1.4.2 - Basic Concepts for business usage of dependent.

Information Receiver
The information receiver is the entity that is asking the questions in a 270 Eligibility or
Benefit transaction. The information receiver is typically the medical service provider
(e.g., physician, hospital, pharmacy, DME supplier, laboratory, etc.). The information
receiver could also be another insurer or payer when they are attempting to verify other
insurance coverage for their members. The information receiver could also be an
employer inquiring on coverage of an employee. The information receiver’s role in the
transaction is identified in the Information Receiver Name segment (2100B NM1).

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Information Source
The information source is the entity that has the answer to the questions being asked
in a 270 Eligibility or Benefit transaction. The information source is typically the insurer,
or payer. In a managed care environment, the information source could possibly be a
primary care physician or gateway provider. Regardless of the information source’s
actual role, they are the entity who maintains the information regarding the patient’s
coverage. The information source is not a clearinghouse, value added network or other
intermediary, even if they hold the data for the true information source. The information
source’s role in the transaction is identified in the Information Source Name segment
(2100A loop NM1).

Patient
The patient is the person who the inquiry and response are for. There is no HL loop
dedicated to patient, rather, the patient can be either the subscriber or the dependent.
Different types of information sources identify patients in different manners depending
upon how their eligibility system is structured. See Section 1.4.2 - Basic Concepts for
business usage of patient.

Real Time
Transactions that are used in a real time mode typically are those that require an
immediate response. In a real time mode, the sender sends a request transaction to the
receiver, either directly or through a clearinghouse (switch), and remains connected
while the receiver processes the transaction and returns a response transaction to the
original sender. Typically, response times range from a few seconds to around thirty
seconds, and should not exceed one minute. See Section 1.4.3 - Batch and Real Time
for business usage of Real Time transactions.

Subscriber
The subscriber is a person who can be uniquely identified to an information source by
a unique Member Identification Number (which may include a unique suffix to the primary
policy holder’s identification number). The subscriber may or may not be the patient.
See definition of patient above for further detail. See Section 1.4.2 - Basic Concepts for
business usage of subscriber.

1.6 Transaction Acknowledgments

There are several acknowledgment implementation transactions available for use. The
IG developers have noted acknowledgment requirements in this section. Other
recommendations of acknowledgment transactions may be used at the discretion of the

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trading partners. A statement that the acknowledgment is not required does not preclude
its use between willing trading partners.

1.6.1 997 Functional Acknowledgment

The 997 informs the submitter that the functional group arrived at the destination. It may
include information about the syntactical quality of the functional group.

The Functional Acknowledgment (997) transaction is not required as a response to

receipt of a batch transaction compliant with this implementation guide.

The Functional Acknowledgment (997) transaction is not required as a response to

receipt of a real-time transaction compliant with this implementation guide.

A 997 Implementation Guide is being developed for use by the insurance industry and
is expected to be available for use with this version of this Implementation Guide.

1.6.2 999 Implementation Acknowledgment

The 999 informs the submitter that the functional group arrived at the destination. It may
include information about the syntactical quality of the functional group and the
implementation guide compliance.

The Implementation Acknowledgment (999) transaction is required as a response to

receipt of a batch transaction compliant with this implementation guide. The 999
Implementation Acknowledgement will also report Implementation Guide errors that
cannot otherwise be reported in a 271 AAA segment if the transaction is rejected. See
Section 1.4.10 - Rejected Transactions.

The Implementation Acknowledgment (999) transaction is not required as a response

to receipt of a real-time transaction compliant with this implementation guide. The 999
Implementation Acknowledgment is required only if a real-time transaction is rejected
for Implementation Guide errors that cannot otherwise be reported in a 271 AAA segment.
See Section 1.4.10 - Rejected Transactions.

A 999 Implementation Guide is being developed for use by the insurance industry and
is expected to be available for use with this version of this Implementation Guide.

1.6.3 824 Application Advice

The 824 informs the submitter of the results of the receiving application system's data
content edits of transaction sets.

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The Application Advice (824) transaction is not required as a response to receipt of a

batch transaction compliant with this implementation guide.

The Application Advice (824) transaction is not required as a response to receipt of a

real-time transaction compliant with this implementation guide.

An 824 Implementation Guide is being developed for use by the insurance industry and
is expected to be available for use with this version of this Implementation Guide.

1.7 Related Transactions

There are no transactions related to the transactions described in this implementation
guide.

1.8 Trading Partner Agreements

Trading partner agreements are used to establish and document the relationship between
trading partners. A trading partner agreement must not override the specifications in this
implementation guide if a transmission is reported in GS08 to be a product of this
implementation guide.

1.9 HIPAA Role in Implementation Guides

Administrative Simplification provisions of the Health Insurance Portability and
Accountability Act of 1996 (PL 104-191 - known as HIPAA) direct the Secretary of Health
and Human Services to adopt standards for transactions to enable health information
to be exchanged electronically and to adopt specifications for implementing each
standard.

This implementation guide has been developed for use as an insurance industry
implementation guide. At the time of publication it has not been adopted as a HIPAA
standard. Should the Secretary adopt this implementation guide as a standard, the
Secretary will establish compliance dates for its use by HIPAA covered entities.

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1.10 Data Overview

1.10.1 Overall Data Architecture
NOTE
See Appendix B, Nomenclature, to review the transaction set structure, including
descriptions of segments, data elements, levels, and loops.

1.10.2 Data Use by Business Use

The 270/271 transactions are divided into two levels, or tables. See Section 2 Transaction
Set, for a description of the transaction sets.

The Header Level, Table 1, contains transaction structure information.

The Detail Level, Table 2, contains specific information about the insurer, requester of
information, insured, and dependents. This implementation uses four different ways to
use the segments in table 2. Each HL is assigned a number identifying its purpose.

• Loop 2000A (information source) contains information typically about the insurer/payer.
• Loop 2000B (information receiver) contains information typically about the medical
service provider. (e.g., physician, hospital, laboratory, etc.).
• Loop 2000C (subscriber) contains information about the individual who can be uniquely
identified to the information source (who may or may not be the patient).
• Loop 2000D (dependent) contains information about dependents of an insured member.

1.11 HIPAA Privacy

The HIPAA Privacy Rule requires covered entities to use the "minimum necessary"
individually identifiable health information to complete the task at hand. Prior to this
requirement, many senders simplified the inquiry process by transmitting all available
information to all trading partners. Now, covered entities must send the minimum
necessary individually identifiable information to each trading partner.

This Implementation Guide in many cases prohibits sending individually identifiable

information unless the sender is certain that the information is needed for the successful
completion of the transaction. While this may aid a covered entity in determining what

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information is minimally necessary, it remains the sole responsibility of the sender to

ensure that they comply with the HIPAA Privacy Rule.

1.12 About the Authors

This transaction set and implementation guide have been developed by the Eligibility
Work Group (WG1) which is part of the Health Care Task Group (TG2) within Insurance
Subcommittee of X12 (X12N), which is an Accredited Standards Committee (ASC) under
ANSI (American National Standards Institute). X12 is responsible for writing transaction
standards for EDI. WG1 is comprised of numerous representatives from the health
industry, including:

• health insurance companies

• health care providers
• health care systems vendors
• information network providers
• independent health care consultants
• state and federal health agencies
• translation software vendors

This implementation guide represents the best efforts of these organizations to bring
forward the information and business requirements associated with this business process.
As new or refined business requirements are identified, changes to this implementation
guide will be made through this WG. Anyone wishing to make changes or additions to
this implementation guide should contact one of the co-chairs of the WG. Co-chairs are
listed with DISA (Data Interchange Standards Association), which is the secretariat for
X12.

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2 Transaction Set
NOTE
See Appendix B, Nomenclature, to review the transaction set structure, including
descriptions of segments, data elements, levels, and loops.

2.1 Presentation Examples

The ASC X12 standards are generic. For example, multiple trading communities
use the same PER segment to specify administrative communication contacts.
Each community decides which elements to use and which code values in those
elements are applicable.
This implementation guide uses a format that depicts both the generalized stand-
ard and the insurance industry-specific implementation. In this implementation
guide, IMPLEMENTATION specifies the requirements for this implementation.
X12 STANDARD is included as a reference only.
The transaction set presentation is comprised of two main sections with subsec-
tions within the main sections:
2.3 Transaction Set Listing
There are two sub-sections under this general title. The first sub-section
concerns this implementation of a generic X12 transaction set. The
second sub-section concerns the generic X12 standard itself.
IMPLEMENTATION
This section lists the levels, loops, and segments contained in this
implementation. It also serves as an index to the segment detail.
STANDARD
This section is included as a reference.
2.4 Segment Detail
There are three sub-sections under this general title. This section repeats
once for each segment used in this implementation providing segment
specific detail and X12 standard detail.
SEGMENT DETAIL
This section is included as a reference.
DIAGRAM
This section is included as a reference. It provides a pictorial view
of the standard and shows which elements are used in this
implementation.
ELEMENT DETAIL
This section specifies the implementation details of each data
element.

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These illustrations (Figures 2.1 through 2.5) are examples and are not extracted
from the Section 2 detail in this implementation guide. Annotated illustrations, pre-
sented below in the same order they appear in this implementation guide, de-
scribe the format of the transaction set that follows.

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IMPLEMENTATION

Indicates that
this section is
the implementation
8XX Insurance Transaction Set
and not the standard

Table 1 - Header
PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

53 0100 ST Transaction Set Header Each segment is assigned an R 1

Segment
54 0200 BPR Financial Information industry specific name. Not R 1
repeats and
60 0400 TRN Reassociation Key used segments do not appear R 1 loop repeats
62 0500 CUR Non-US Dollars Currency S 1 reflect actual
65 0600 REF Receiver ID Each loop is assigned an S 1 usage
66 0600 REF Version Number industry specific name S 1
68 0700 DTM Production Date S 1
PAYER NAME 1
70 0800 N1 Payer Name R 1
72 1000 N3 Payer Address R=Required S 1
75 1100 N4 Payer City, State, Zip S=Situational S 1
76 1200 REF Additional Payer Reference Number S 1
78 1300 PER Payer Contact S 1
PAYEE NAME 1
79 0800 N1 Payee Name R 1
81 1000 N3 Payee Address S 1
82 1100 N4 Payee City, State, Zip S 1
84 1200 REF Payee Additional Reference Number S >1

Position Numbers and Segment IDs retain their X12 values Individual segments and entire loops are repeated

Figure 2.1. Transaction Set Key — Implementation

STANDARD

Indicates that 8XX Insurance Transaction Set

this section is identical
to the ASC X12 standard
Functional Group ID: XX
This Draft Standard for Trial Use contains the format and establishes the data contents of
See Appendix B.1, ASC the Insurance Transaction Set (8XX) within the context of the Electronic Data Interchange
X12 Nomenclature for a (EDI) environment.
complete description of
the standard

Table 1 - Header
POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

0100 ST Transaction Set Header M 1

0200 BPR Beginning Segment M 1
0300 NTE Note/Special Instruction O >1
0400 TRN Trace O 1

Figure 2.2. Transaction Set Key — Standard

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SEGMENT DETAIL
Industry assigned
Segment Name NM1 - PATIENT NAME
X12 Segment Name: Individual or Organizational Name See section
B.1.1.3.8 for
X12 Purpose: To supply the full name of an individual or organizational entity a description
of these
X12 Syntax: 1. P0809 values
If either NM108 or NM109 is present, then the other is required.
2. C1110
Industry assigned If NM111 is present, then NM110 is required.
Loop ID and Loop 3. C1203
Name Industry Loop Repeat
If NM112 is present, then NM103 is required.
Industry Segment
Repeat
Loop: 2100B — PATIENT NAME Loop Repeat: 1

Segment Repeat: 1
Industry
usage
Usage: SITUATIONAL

Situational Rule: Required when the patient is different from the insured. If not required by this
Situational implementation guide, do not send.
Rule
TR3 Notes: 1. Any necessary identification number must be provided in NM109.
Industry
Notes TR3 Example: NM1✽QC✽1✽Shepard✽Sam✽A✽✽✽34✽452114586~

Example

Figure 2.3. Segment Key — Implementation

DIAGRAM

Indicates a Element Abbreviated Segment

Required Element Delimiter Element Name Terminator

N101 98 N102 93 N103 66 N104 67 N105 706 N106 98

Entity ID Name ID Code ID Entity Entity ID ~
N1 ✽ Code
✽ ✽
Qualifier
✽
Code
✽
Relat Code
✽
Code
M1 ID 2/2 X1 AN 1/35 X1 ID 1/2 X1 AN 2/20 O1 ID 2/2 O1 ID 2/2

Segment ID
Requirement Minimum/ Data Element Indicates a Indicates a Not
Designator Maximum Length Type Repeat Situational Element Used Element

Figure 2.4. Segment Key — Diagram

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ELEMENT DETAIL

REF. DATA Element Repeat

USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED SVC01 C003 COMPOSITE MEDICAL PROCEDURE M1

IDENTIFIER
To identify a medical procedure by its standardized codes and
Reference Designator Composite applicable modifiers
Number
124 Use the Primary Payer’s adjudicated Medical Procedure Code.
REQUIRED SVC01 - 1 235 Product/Service ID Qualifier M ID 2/2
Code identifying the type/source of the descriptive number
Industry Usage: used in Product/Service ID (234)
See the following
IMPLEMENTATION NAME: Product or Service ID Qualifier
page for complete
descriptions
127 The value in SVC01-1 qualifies the values in SVC01-2,
Industry Note
SVC01-3, SVC01-4, SVC01-5, and SVC01-6.
CODE DEFINITION

Selected Code Values AD American Dental Association Codes

CODE SOURCE 135:American Dental Association
See Appendix A for HP Health Insurance Prospective Payment System
external code source (HIPPS) Skilled Nursing Facility Rate Code
reference
CODE SOURCE 716: Health Insurance Prospective
Payment System (HIPPS) Rate Code for Skilled
Nursing Facilities
REQUIRED SVC01 - 2 234 Product/Service ID M AN 1/48
Identifying number for a product or service
NOT USED SVC01 - 3 1339 Procedure Modifier O AN 2/2
NOT USED SVC01 - 4 1339 Procedure Modifier O AN 2/2
NOT USED SVC01 - 5 1339 Procedure Modifier O AN 2/2
NOT USED SVC01 - 6 1339 Procedure Modifier O AN 2/2
NOT USED SVC01 - 7 352 Description O AN 1/80
REQUIRED SVC02 782 Monetary Amount M1 R 1/18
Monetary amount
Data Element SEMANTIC: SVC02 is the submitted service charge.
Number
1000112 This value can not be negative.
NOT USED SVC03 782 Monetary Amount O1 R 1/18
SITUATIONAL SVC04 234 Product/Service ID O1 AN 1/48
Identifying number for a product or service
X12 Semantic Note
SEMANTIC: SVC04 is the National Uniform Billing Committee Revenue Code.
Situational Rule SITUATIONAL RULE: Required
when an NUBC revenue code was
considered during adjudication in addition to a procedure code
Implementation Name already identified in SVC01. If not required by this
See Appendix E for implementation guide, do not send.
definition
IMPLEMENTATION NAME: National Uniform Billing Committee Revenue
Code

Figure 2.5. Segment Key — Element Summary

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2.2 Implementation Usage

2.2.1 Industry Usage
Industry Usage describes when loops, segments, and elements are to be sent
when complying with this implementation guide. The three choices for Usage are
required, not used, and situational. To avoid confusion, these are named differ-
ently than the X12 standard Condition Designators (mandatory, optional, and rela-
tional).

Required This loop/segment/element must always be sent.

Required segments in Situational loops only occur when the loop

is used.

Required elements in Situational segments only occur when the

segment is used.

Required component elements in Situational composite ele-

ments only occur when the composite element is used.

Not Used This element must never be sent.

Situational Use of this loop/segment/element varies, depending on data con-

tent and business context as described in the defining rule. The
defining rule is documented in a Situational Rule attached to the
item.

There are two forms of Situational Rules.

The first form is “Required when <explicit condition statement>.

If not required by this implementation guide, may be provided at
the sender’s discretion, but cannot be required by the receiver.”
The data qualified by such a situational rule cannot be required
or requested by the receiver, transmission of this data is solely at
the sender’s discretion.

The alternative form is “Required when <explicit condition state-

ment>. If not required by this implementation guide, do not
send.” The data qualified by such a situational rule cannot be
sent except as described in the explicit condition statement.

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2.2.1.1 Transaction Compliance Related to Industry Usage

A transmitted transaction complies with an implementation guide when it satisfies
the requirements as defined within the implementation guide. The presence or ab-
sence of an item (loop, segment, or element) complies with the industry usage
specified by this implementation guide according to the following table.

Transaction
Business Complies with
Condition Item Implementation
Industry Usage is is Guide?

Required Sent Yes

N/A
Not Sent No
Not Used Sent No
N/A
Not Sent Yes
Situational (Required when <explicit Sent Yes
condition statement>. If not required by True
this implementation guide, may be Not Sent No
provided at the sender’s discretion, but Sent Yes
cannot be required by the receiver.) Not True
Not Sent Yes
Situational (Required when <explicit Sent Yes
True
condition statement>. If not required by Not Sent No
this implementation guide, do not send.) Sent No
Not True
Not Sent Yes

This table specifies how an entity is to evaluate a transmitted transaction for com-
pliance with industry usage. It is not intended to require or imply that the receiver
must reject non-compliant transactions. The receiver will handle non-compliant
transactions based on its business process and any applicable regulations.

2.2.2 Loops
Loop requirements depend on the context or location of the loop within the trans-
action. See Appendix B for more information on loops.
• A nested loop can be used only when the associated higher level loop is used.
• The usage of a loop is the same as the usage of its beginning segment.
• If a loop’s beginning segment is Required, the loop is Required and must oc-
cur at least once unless it is nested in a loop that is not being used.
• If a loop’s beginning segment is Situational, the loop is Situational.
• Subsequent segments within a loop can be sent only when the beginning seg-
ment is used.
• Required segments in Situational loops occur only when the loop is used.

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2.3 Transaction Set Listing

2.3.1 Implementation
This section lists the levels, loops, and segments contained in this implementa-
tion. It also serves as an index to the segment detail. Refer to section 2.1 Presen-
tation Examples for detailed information on the components of the
Implementation section.

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MARCH 28, 2008

IMPLEMENTATION

270 Health Care Eligibility Benefit Inquiry

Table 1 - Header
PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

61 0100 ST Transaction Set Header R 1

63 0200 BHT Beginning of Hierarchical Transaction R 1

Table 2 - Information Source Detail

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

LOOP ID - 2000A INFORMATION SOURCE LEVEL >1

66 0100 HL Information Source Level R 1
LOOP ID - 2100A INFORMATION SOURCE NAME 1
69 0300 NM1 Information Source Name R 1

Table 2 - Information Receiver Detail

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

LOOP ID - 2000B INFORMATION RECEIVER LEVEL >1

72 0100 HL Information Receiver Level R 1
LOOP ID - 2100B INFORMATION RECEIVER NAME 1
75 0300 NM1 Information Receiver Name R 1
79 0400 REF Information Receiver Additional Identification S 9
81 0600 N3 Information Receiver Address S 1
82 0700 N4 Information Receiver City, State, ZIP Code S 1
84 0900 PRV Information Receiver Provider Information S 1

Table 2 - Subscriber Detail

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

LOOP ID - 2000C SUBSCRIBER LEVEL >1

86 0100 HL Subscriber Level R 1
90 0200 TRN Subscriber Trace Number S 2
LOOP ID - 2100C SUBSCRIBER NAME 1
92 0300 NM1 Subscriber Name R 1
97 0400 REF Subscriber Additional Identification S 9
100 0600 N3 Subscriber Address S 1
101 0700 N4 Subscriber City, State, ZIP Code S 1
103 0900 PRV Provider Information S 1
107 1000 DMG Subscriber Demographic Information S 1
110 1100 INS Multiple Birth Sequence Number S 1
113 1150 HI Subscriber Health Care Diagnosis Code S 1

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122 1200 DTP Subscriber Date S 2

LOOP ID - 2110C SUBSCRIBER ELIGIBILITY OR 99
BENEFIT INQUIRY
124 1300 EQ Subscriber Eligibility or Benefit Inquiry S 1
136 1350 AMT Subscriber Spend Down Amount S 1
137 1350 AMT Subscriber Spend Down Total Billed Amount S 1
138 1700 III Subscriber Eligibility or Benefit Additional Inquiry S 1
Information
142 1900 REF Subscriber Additional Information S 1
144 2000 DTP Subscriber Eligibility/Benefit Date S 1

Table 2 - Dependent Detail

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

LOOP ID - 2000D DEPENDENT LEVEL >1

146 0100 HL Dependent Level S 1
149 0200 TRN Dependent Trace Number S 2
LOOP ID - 2100D DEPENDENT NAME 1
151 0300 NM1 Dependent Name R 1
154 0400 REF Dependent Additional Identification S 9
157 0600 N3 Dependent Address S 1
158 0700 N4 Dependent City, State, ZIP Code S 1
160 0900 PRV Provider Information S 1
164 1000 DMG Dependent Demographic Information S 1
167 1100 INS Dependent Relationship S 1
170 1150 HI Dependent Health Care Diagnosis Code S 1
179 1200 DTP Dependent Date S 2
LOOP ID - 2110D DEPENDENT ELIGIBILITY OR 99
BENEFIT INQUIRY
181 1300 EQ Dependent Eligibility or Benefit Inquiry R 1
192 1700 III Dependent Eligibility or Benefit Additional Inquiry S 1
Information
196 1900 REF Dependent Additional Information S 1
198 2000 DTP Dependent Eligibility/Benefit Date S 1
200 2100 SE Transaction Set Trailer R 1

APRIL 2008 57
 ASC X12N • INSURANCE SUBCOMMITTEE
005010X279 • 270 TECHNICAL REPORT • TYPE 3

2.3.2 X12 Standard

This section is included as a reference. The implementation guide reference clari-
fies actual usage. Refer to section 2.1 Presentation Examples for detailed infor-
mation on the components of the X12 Standard section.

58 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE
TECHNICAL REPORT • TYPE 3 005010X279 • 270

STANDARD

270 Eligibility, Coverage or Benefit Inquiry

Functional Group ID: HS
This X12 Transaction Set contains the format and establishes the data contents of the Eligibility,
Coverage or Benefit Inquiry Transaction Set (270) for use within the context of an Electronic
Data Interchange (EDI) environment. This transaction set can be used to inquire about the
eligibility, coverages or benefits associated with a benefit plan, employer, plan sponsor,
subscriber or a dependent under the subscriber’s policy. The transaction set is intended to be
used by all lines of insurance such as Health, Life, and Property and Casualty.

Table 1 - Header

PAGE # POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

0100 ST Transaction Set Header M 1

0200 BHT Beginning of Hierarchical Transaction M 1

Table 2 - Detail

PAGE # POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

LOOP ID - 2000 >1

0100 HL Hierarchical Level M 1
0200 TRN Trace O 9
LOOP ID - 2100 >1
0300 NM1 Individual or Organizational Name M 1
0400 REF Reference Information O 9
0500 N2 Additional Name Information O 1
0600 N3 Party Location O 1
0700 N4 Geographic Location O 1
0800 PER Administrative Communications Contact O 3
0900 PRV Provider Information O 1
1000 DMG Demographic Information O 1
1100 INS Insured Benefit O 1
1150 HI Health Care Information Codes O 1
1200 DTP Date or Time or Period O 9
1250 MPI Military Personnel Information O 9
LOOP ID - 2110 99
1300 EQ Eligibility or Benefit Inquiry O 1
1350 AMT Monetary Amount Information O 2
1400 VEH Vehicle Information O 1
1500 PDR Property Description - Real O 1
1600 PDP Property Description - Personal O 1
1700 III Information O 10
1900 REF Reference Information O 1
2000 DTP Date or Time or Period O 9
2100 SE Transaction Set Trailer M 1
NOTE:
2/0200 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.

APRIL 2008 59
 ASC X12N • INSURANCE SUBCOMMITTEE
005010X279 • 270 TECHNICAL REPORT • TYPE 3

2.4 270 - Segment Detail

This section specifies the segments, data elements, and codes for this implemen-
tation. Refer to section 2.1 Presentation Examples for detailed information on the
components of the Segment Detail section.

60 APRIL 2008
 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • ST
TECHNICAL REPORT • TYPE 3 TRANSACTION SET HEADER
TRANSACTION SET HEADER TRANSACTION
005010X279 • 270
SET• ST
HEADER
ST

SEGMENT DETAIL
123
300
ST - TRANSACTION SET HEADER
X12 Segment Name: Transaction Set Header
X12 Purpose: To indicate the start of a transaction set and to assign a control number
Segment Repeat: 1

Usage: REQUIRED

028
300 TR3 Notes: 1. Use this control segment to mark the start of a transaction set. One
ST segment exists for every transaction set that occurs within a
functional group.

048
300 TR3 Example: ST✽270✽0001✽005010X279~

DIAGRAM

ST01 143 ST02 329 ST03 1705

TS ID TS Control Imple Conv
ST ✽
Code
✽
Number
✽
Reference
~
M1 ID 3/3 M1 AN 4/9 O1 AN 1/35

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED ST01 143 Transaction Set Identifier Code M1 ID 3/3

Code uniquely identifying a Transaction Set
SEMANTIC: The transaction set identifier (ST01) is used by the translation routines
of the interchange partners to select the appropriate transaction set definition
(e.g., 810 selects the Invoice Transaction Set).

OD: 270B1__ST01__TransactionSetIdentifierCode

300029 Use this code to identify the transaction set ID for the transaction
set that will follow the ST segment. Each X12 standard has a
transaction set identifier code that is unique to that transaction set.
CODE DEFINITION

270 Eligibility, Coverage or Benefit Inquiry

REQUIRED ST02 329 Transaction Set Control Number M 1 AN 4/9
Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set

OD: 270B1__ST02__TransactionSetControlNumber

300025 The transaction set control numbers in ST02 and SE02 must be
identical. This unique number also aids in error resolution
research. Start with the number, for example “0001", and increment
from there. This number must be unique within a specific group
and interchange, but can repeat in other groups and interchanges.

300272 Use the corresponding value in SE02 for this transaction set.

APRIL 2008 61
005010X279 • 270 • ST ASC X12N • INSURANCE SUBCOMMITTEE
TRANSACTION SET HEADER TECHNICAL REPORT • TYPE 3

REQUIRED ST03 1705 Implementation Convention Reference O 1 AN 1/35

Reference assigned to identify Implementation Convention
SEMANTIC: The implementation convention reference (ST03) is used by the
translation routines of the interchange partners to select the appropriate
implementation convention to match the transaction set definition. When used,
this implementation convention reference takes precedence over the
implementation reference specified in the GS08.

OD: 270B1__ST03__ImplementationConventionReference

300309 This element must be populated with 005010X279.

300310 This element contains the same value as GS08. Some translator
products strip off the ISA and GS segments prior to application
(ST/SE) processing. Providing the information from the GS08 at this
level will ensure that the appropriate application mapping is utilized
at translation time.

62 APRIL 2008
 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • BHT
TECHNICAL REPORT • TYPE 3 BEGINNING OF HIERARCHICAL TRANSACTION
BEGINNING OF HIERARCHICAL TRANSACTION 005010X279 • 270
BEGINNING OF • BHT
HIERARCHICAL TRANSACTION
BHT

SEGMENT DETAIL
124
300
BHT - BEGINNING OF HIERARCHICAL
TRANSACTION
X12 Segment Name: Beginning of Hierarchical Transaction
X12 Purpose: 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
Segment Repeat: 1

Usage: REQUIRED

068
300 TR3 Notes: 1. Use this segment to start the transaction set and indicate the
sequence of the hierarchical levels of information that will follow in
Table 2.

072
300 TR3 Example: BHT✽0022✽13✽199800114000001✽19980101✽1400~

162
300 TR3 Example: BHT✽0022✽01✽✽19980101✽1400✽RT~

DIAGRAM

BHT01 1005 BHT02 353 BHT03 127 BHT04 373 BHT05 337 BHT06 640
Hierarch TS Purpose Reference Date Time Transaction
BHT ✽ Struct Code
✽
Code
✽
Ident
✽ ✽ ✽
Type Code ~
M1 ID 4/4 M1 ID 2/2 O1 AN 1/50 O1 DT 8/8 O1 TM 4/8 O1 ID 2/2

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED BHT01 1005 Hierarchical Structure Code M1 ID 4/4

Code indicating the hierarchical application structure of a transaction set that
utilizes the HL segment to define the structure of the transaction set

OD: 270B1__BHT01__HierarchicalStructureCode

300071 Use this code to specify the sequence of hierarchical levels that
may appear in the transaction set. This code only indicates the
sequence of the levels, not the requirement that all levels be
present. For example, if code “0022" is used, the dependent level
may or may not be present for each subscriber.
CODE DEFINITION

0022 Information Source, Information Receiver,

Subscriber, Dependent

APRIL 2008 63
005010X279 • 270 • BHT ASC X12N • INSURANCE SUBCOMMITTEE
BEGINNING OF HIERARCHICAL TRANSACTION TECHNICAL REPORT • TYPE 3

REQUIRED BHT02 353 Transaction Set Purpose Code M1 ID 2/2

Code identifying purpose of transaction set

OD: 270B1__BHT02__TransactionSetPurposeCode

CODE DEFINITION

01 Cancellation
300132 Use this code to cancel a previously submitted 270
transaction that used a BHT06 code of “RT”. Only
270 transactions that used a BHT06 code of “RT”
can be canceled. The cancellation 270 transaction
must also contain a BHT06 of “RT”.
13 Request
SITUATIONAL BHT03 127 Reference Identification O 1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SEMANTIC: BHT03 is the number assigned by the originator to identify the
transaction within the originator’s business application system.

300302 SITUATIONAL RULE: Requiredwhen the transaction is processed in Real

Time. If not required by this implementation guide, may be provided
at the sender’s discretion, but cannot be required by the receiver.

OD: 270B1__BHT03__SubmitterTransactionIdentifier

IMPLEMENTATION NAME: Submitter Transaction Identifier

300346 Due to the nature of batch transaction processing, the receiver of

the 270 transaction (whether it is a clearinghouse or information
source) may or may not be able to return the 270 BHT03 value in
the 271 BHT03. See Section 1.4.6 Information Linkage for additional
information and requirements.

300303 This element is to be used to trace the transaction from one point
to the next point, such as when the transaction is passed from one
clearinghouse to another clearinghouse. This identifier is to be
returned in the corresponding 271 transaction’s BHT03. This
identifier will only be returned by the last entity to handle the 270.
This identifier will not be passed through the complete life of the
transaction.
REQUIRED BHT04 373 Date O1 DT 8/8
Date expressed as CCYYMMDD where CC represents the first two digits of the
calendar year
SEMANTIC: BHT04 is the date the transaction was created within the business
application system.

OD: 270B1__BHT04__TransactionSetCreationDate

IMPLEMENTATION NAME: Transaction Set Creation Date

300069 Use this date for the date the transaction set was generated.

64 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • BHT
TECHNICAL REPORT • TYPE 3 BEGINNING OF HIERARCHICAL TRANSACTION

REQUIRED BHT05 337 Time O 1 TM 4/8

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S =
integer seconds (00-59) and DD = decimal seconds; decimal seconds are
expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC: BHT05 is the time the transaction was created within the business
application system.

OD: 270B1__BHT05__TransactionSetCreationTime

IMPLEMENTATION NAME: Transaction Set Creation Time

300070 Use this time for the time the transaction set was generated.
SITUATIONAL BHT06 640 Transaction Type Code O1 ID 2/2
Code specifying the type of transaction

300347 SITUATIONAL RULE: Required when the Information Source supports

Spend Down transactions and the Information Receiver is using
this transaction for Spend Down purposes. If not required by this
implementation guide, do not send.

OD: 270B1__BHT06__TransactionTypeCode

300198 Certain Medicaid programs support additional functionality for

Spend Down. Use this code when necessary to further specify the
type of transaction to a Medicaid program that supports this
functionality.
CODE DEFINITION

RT Spend Down
300306 “Spend Down” is a term used by certain Medicaid
programs when a recipient must pay a
predetermined amount out of his or her own pocket
before full coverage benefits are applied. In order to
decrement the amount the recipient must pay out of
pocket, a 270 transaction must be sent in with this
code.

In the event that the service is not rendered and the

Spend Down amount is returned to the recipient, an
additional 270 must be sent in with a BHT02 with a
code “01" to cancel the Spend Down.

APRIL 2008 65
 005010X279 • 270 • 2000A • HL ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION SOURCE LEVEL TECHNICAL REPORT • TYPE 3
HIERARCHICAL LEVEL 005010X279
INFORMATION• 270 • 2000A
SOURCE • HL
LEVEL
HL

SEGMENT DETAIL
079
300
HL - INFORMATION SOURCE LEVEL
X12 Segment Name: Hierarchical Level
X12 Purpose: To identify dependencies among and the content of hierarchically related
groups of data segments
X12 Comments: 1. The HL segment is used to identify levels of detail information using a
hierarchical structure, such as relating line-item data to shipment data, and
packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
Loop: 2000A — INFORMATION SOURCE LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: REQUIRED

024
300 TR3 Notes: 1. Use this segment to identify the hierarchical or entity level of
information being conveyed. The HL structure allows for the efficient
nesting of related occurrences of information. The developers’ intent
is to clearly identify the relationship of the patient to the subscriber
and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient)

can be grouped together under the same provider or the information
for multiple providers or information receivers can be grouped
together for the same payer or information source. See Section 1.3.2
for limitations on the number of occurrences of patients.

142
300 2. In a batch environment, only one Loop 2000A (Information Source)
loop is to be created for each unique information source in a
transaction. Each Loop 2000B (Information Receiver) loop that is
subordinate to an information source is to be contained within only
one Loop 2000A loop. There has been a misuse of the HL structure
creating multiple Loops 2000As for the same information source. This
is not the developer’s intended use of the HL structure, and defeats
the efficiencies that are designed into the HL structure.

075
300 3. An example of the overall structure of the transaction set when used
in batch mode is:

Information Source (Loop 2000A)

Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry

049
300 TR3 Example: HL✽1✽✽20✽1~

66 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2000A • HL
TECHNICAL REPORT • TYPE 3 INFORMATION SOURCE LEVEL

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736

Hierarch Hierarch Hierarch Hierarch
HL ✽ ID Number
✽
Parent ID
✽
Level Code
✽
Child Code
~
M1 AN 1/12 O1 AN 1/12 M1 ID 1/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HL01 628 Hierarchical ID Number M 1 AN 1/12

A unique number assigned by the sender to identify a particular data segment in
a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence
of the HL segment in the transaction set. For example, HL01 could be used to
indicate the number of occurrences of the HL segment, in which case the value of
HL01 would be “1" for the initial HL segment and would be incremented by one in
each subsequent HL segment within the transaction.

OD: 270B1_2000A_HL01__HierarchicalIDNumber

300031 Use this sequentially assigned positive number to identify each

specific occurrence of an HL segment within a transaction set. The
first HL segment in the transaction must begin with the number one
and be incremented by one for each successive occurrence of the
HL segment within that specific transaction set (ST through SE).

300032 An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
NOT USED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12
REQUIRED HL03 735 Hierarchical Level Code M1 ID 1/2
Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the
current HL segment up to the next occurrence of an HL segment in the
transaction. For example, HL03 is used to indicate that subsequent segments in
the HL loop form a logical grouping of data referring to shipment, order, or item-
level information.

OD: 270B1_2000A_HL03__HierarchicalLevelCode

300311 All data that follows this HL segment is associated with the
Information Source identified by the level code. This association
continues until the next occurrence of an HL segment.
CODE DEFINITION

20 Information Source

APRIL 2008 67
005010X279 • 270 • 2000A • HL ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION SOURCE LEVEL TECHNICAL REPORT • TYPE 3

REQUIRED HL04 736 Hierarchical Child Code O1 ID 1/1

Code indicating if there are hierarchical child data segments subordinate to the
level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL
segments related to the current HL segment.

OD: 270B1_2000A_HL04__HierarchicalChildCode

300312 Because of the hierarchical structure, and there will always be an

Information Receiver HL subordinate to this Information Source HL
the code value in the HL04 at the Loop 2000A level must always be
“1".
CODE DEFINITION

1 Additional Subordinate HL Data Segment in This

Hierarchical Structure.

68 APRIL 2008
 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100A • NM1
TECHNICAL REPORT • TYPE 3 INFORMATION SOURCE NAME
INDIVIDUAL OR ORGANIZATIONAL NAME 005010X279
INFORMATION• 270 • 2100A
SOURCE • NM1
NAME
NM1

SEGMENT DETAIL
080
300
NM1 - INFORMATION SOURCE NAME
X12 Segment Name: Individual or Organizational Name
X12 Purpose: To supply the full name of an individual or organizational entity
X12 Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
3. C1203
If NM112 is present, then NM103 is required.
Loop: 2100A — INFORMATION SOURCE NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

026
300 TR3 Notes: 1. Use this NM1 loop to identify an entity by name and/or identification
number. This NM1 loop is used to identify the eligibility or benefit
information source, (e.g., insurance company, HMO, IPA, employer).

050
300 TR3 Example: NM1✽PR✽2✽ACE INSURANCE COMPANY✽✽✽✽✽PI✽87728~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038
Entity ID Entity Type Name Last/ Name Name Name
NM1 ✽
Code
✽
Qualifier
✽
Org Name
✽
First
✽
Middle
✽
Prefix
M1 ID 2/3 M1 ID 1/1 X1 AN 1/60 O1 AN 1/35 O1 AN 1/25 O1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

Name ID Code ID Entity Entity ID Name Last/
✽ ✽ ✽ ✽ ✽ ✽ ~
Suffix Qualifier Code Relat Code Code Org Name
O1 AN 1/10 X1 ID 1/2 X1 AN 2/80 X1 ID 2/2 O1 ID 2/3 O1 AN 1/60

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED NM101 98 Entity Identifier Code M1 ID 2/3

Code identifying an organizational entity, a physical location, property or an
individual

OD: 270B1_2100A_NM101__EntityIdentifierCode

CODE DEFINITION

2B Third-Party Administrator
36 Employer
GP Gateway Provider
P5 Plan Sponsor
PR Payer

APRIL 2008 69
005010X279 • 270 • 2100A • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION SOURCE NAME TECHNICAL REPORT • TYPE 3

REQUIRED NM102 1065 Entity Type Qualifier M1 ID 1/1

Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.

OD: 270B1_2100A_NM102__EntityTypeQualifier

300027 Use this code to indicate whether the entity is an individual person
or an organization.
CODE DEFINITION

1 Person
300275 Use this code only if the information source is a
Gateway Provider and an individual.
2 Non-Person Entity
REQUIRED NM103 1035 Name Last or Organization Name X1 AN 1/60
Individual last name or organizational name
SYNTAX: C1203

OD:
270B1_2100A_NM103__InformationSourceLastorOrganizationName

IMPLEMENTATION NAME: Information Source Last or Organization Name

SITUATIONAL NM104 1036 Name First O 1 AN 1/35
Individual first name

300397 SITUATIONAL RULE: Requiredwhen NM102 = 1 (person) and the person

has a first name. If not required by this implementation guide, do
not send.

OD: 270B1_2100A_NM104__InformationSourceFirstName

IMPLEMENTATION NAME: Information Source First Name

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25
Individual middle name or initial

300348 SITUATIONAL RULE: Required when NM102 is “1" and the identifier in
2100A NM109 and Last Name in 2100A NM103 and First Name in
2100A NM104 and Name Suffix in 2100A NM107 if sent, are not
sufficient to identify the source of eligibility or benefit information.
If not required by this implementation guide, may be provided at
sender’s discretion, but cannot be required by the receiver.

OD: 270B1_2100A_NM105__InformationSourceMiddleName

IMPLEMENTATION NAME: Information Source Middle Name

NOT USED NM106 1038 Name Prefix O 1 AN 1/10

70 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100A • NM1
TECHNICAL REPORT • TYPE 3 INFORMATION SOURCE NAME

SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10

Suffix to individual name

300349 SITUATIONAL RULE: Required when NM102 is “1" and the identifier in
2100A NM109 and Last Name in 2100A NM103 and First Name in
2100A NM104 and Middle Name in 2100A NM105 if sent, are not
sufficient to identify the source of eligibility or benefit information.
If not required by this implementation guide, may be provided at
sender’s discretion, but cannot be required by the receiver.

OD: 270B1_2100A_NM107__InformationSourceNameSuffix

IMPLEMENTATION NAME: Information Source Name Suffix

REQUIRED NM108 66 Identification Code Qualifier X1 ID 1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX: P0809

OD: 270B1_2100A_NM108__IdentificationCodeQualifier

300141 Use code value “XV” if the Information Source is a Payer and the
National PlanID is mandated for use. Use code value “XX” if the
information source is a provider and the CMS National Provider
Identifier is mandated for use. Otherwise one of the other
appropriate code values may be used.
CODE DEFINITION

24 Employer’s Identification Number

46 Electronic Transmitter Identification Number (ETIN)
FI Federal Taxpayer’s Identification Number
NI National Association of Insurance Commissioners
(NAIC) Identification
PI Payor Identification
XV Centers for Medicare and Medicaid Services PlanID
CODE SOURCE 540: Centers for Medicare and Medicaid Services
PlanID
XX Centers for Medicare and Medicaid Services
National Provider Identifier
CODE SOURCE 537: Centers for Medicare & Medicaid Services
National Provider Identifier
REQUIRED NM109 67 Identification Code X1 AN 2/80
Code identifying a party or other code
SYNTAX: P0809

OD: 270B1_2100A_NM109__InformationSourcePrimaryIdentifier

IMPLEMENTATION NAME: Information Source Primary Identifier

NOT USED NM110 706 Entity Relationship Code X1 ID 2/2
NOT USED NM111 98 Entity Identifier Code O1 ID 2/3
NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

APRIL 2008 71
 005010X279 • 270 • 2000B • HL ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER LEVEL TECHNICAL REPORT • TYPE 3
HIERARCHICAL LEVEL 005010X279
INFORMATION• 270 • 2000B LEVEL
RECEIVER • HL
HL

SEGMENT DETAIL
081
300
HL - INFORMATION RECEIVER LEVEL
X12 Segment Name: Hierarchical Level
X12 Purpose: To identify dependencies among and the content of hierarchically related
groups of data segments
X12 Comments: 1. The HL segment is used to identify levels of detail information using a
hierarchical structure, such as relating line-item data to shipment data, and
packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
Loop: 2000B — INFORMATION RECEIVER LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: REQUIRED

024
300 TR3 Notes: 1. Use this segment to identify the hierarchical or entity level of
information being conveyed. The HL structure allows for the efficient
nesting of related occurrences of information. The developers’ intent
is to clearly identify the relationship of the patient to the subscriber
and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient)

can be grouped together under the same provider or the information
for multiple providers or information receivers can be grouped
together for the same payer or information source. See Section 1.3.2
for limitations on the number of occurrences of patients.

143
300 2. In a batch environment, only one Loop 2000B (Information Receiver)
loop is to be created for each unique information receiver within an
Loop 2000A (Information Source) loop. Each Loop 2000C (Subscriber)
loop that is subordinate to an information receiver is to be contained
within only one Loop 2000B loop. There has been a misuse of the HL
structure creating multiple Loop 2000Bs for the same information
receiver within an information source loop. This is not the developer’s
intended use of the HL structure, and defeats the efficiencies that are
designed into the HL structure.

075
300 3. An example of the overall structure of the transaction set when used
in batch mode is:

Information Source (Loop 2000A)

Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry

72 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2000B • HL
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER LEVEL

051
300 TR3 Example: HL✽2✽1✽21✽1~

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736

Hierarch Hierarch Hierarch Hierarch
HL ✽ ID Number
✽
Parent ID
✽
Level Code
✽
Child Code
~
M1 AN 1/12 O1 AN 1/12 M1 ID 1/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HL01 628 Hierarchical ID Number M 1 AN 1/12

A unique number assigned by the sender to identify a particular data segment in
a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence
of the HL segment in the transaction set. For example, HL01 could be used to
indicate the number of occurrences of the HL segment, in which case the value of
HL01 would be “1" for the initial HL segment and would be incremented by one in
each subsequent HL segment within the transaction.

OD: 270B1_2000B_HL01__HierarchicalIDNumber

300031 Use this sequentially assigned positive number to identify each

specific occurrence of an HL segment within a transaction set. The
first HL segment in the transaction must begin with the number one
and be incremented by one for each successive occurrence of the
HL segment within that specific transaction set (ST through SE).

300111 An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~

REQUIRED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12

Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which
the current HL segment is subordinate.

OD: 270B1_2000B_HL02__HierarchicalParentIDNumber

300313 Use this code to identify the specific Information Source to which
this Information Receiver is subordinate.

APRIL 2008 73
005010X279 • 270 • 2000B • HL ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER LEVEL TECHNICAL REPORT • TYPE 3

REQUIRED HL03 735 Hierarchical Level Code M1 ID 1/2

Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the
current HL segment up to the next occurrence of an HL segment in the
transaction. For example, HL03 is used to indicate that subsequent segments in
the HL loop form a logical grouping of data referring to shipment, order, or item-
level information.

OD: 270B1_2000B_HL03__HierarchicalLevelCode

300314 All data that follows this HL segment is associated with the
Information Receiver identified by the level code. This association
continues until the next occurrence of an HL segment.
CODE DEFINITION

21 Information Receiver
REQUIRED HL04 736 Hierarchical Child Code O1 ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL
segments related to the current HL segment.

OD: 270B1_2000B_HL04__HierarchicalChildCode

300315 Because of the hierarchical structure, and there will always be a

Subscriber HL subordinate to this Information Receiver HL, the
code value in the HL04 at the Loop 2000B level must always be “1".
CODE DEFINITION

1 Additional Subordinate HL Data Segment in This

Hierarchical Structure.

74 APRIL 2008
 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100B • NM1
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER NAME
INDIVIDUAL OR ORGANIZATIONAL NAME 005010X279
INFORMATION• 270 • 2100B NAME
RECEIVER • NM1
NM1

SEGMENT DETAIL
082
300
NM1 - INFORMATION RECEIVER NAME
X12 Segment Name: Individual or Organizational Name
X12 Purpose: To supply the full name of an individual or organizational entity
X12 Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
3. C1203
If NM112 is present, then NM103 is required.
Loop: 2100B — INFORMATION RECEIVER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

044
300 TR3 Notes: 1. Use this segment to identify an entity by name and/or identification
number. This NM1 loop is used to identify the eligibility/benefit
information receiver (e.g., provider, medical group, employer, IPA, or
hospital).

055
300 TR3 Example: NM1✽1P✽1✽JONES✽MARCUS✽✽✽MD✽34✽111223333~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038
Entity ID Entity Type Name Last/ Name Name Name
NM1 ✽
Code
✽
Qualifier
✽
Org Name
✽
First
✽
Middle
✽
Prefix
M1 ID 2/3 M1 ID 1/1 X1 AN 1/60 O1 AN 1/35 O1 AN 1/25 O1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

Name ID Code ID Entity Entity ID Name Last/
✽ ✽ ✽ ✽ ✽ ✽ ~
Suffix Qualifier Code Relat Code Code Org Name
O1 AN 1/10 X1 ID 1/2 X1 AN 2/80 X1 ID 2/2 O1 ID 2/3 O1 AN 1/60

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED NM101 98 Entity Identifier Code M1 ID 2/3

Code identifying an organizational entity, a physical location, property or an
individual

OD: 270B1_2100B_NM101__EntityIdentifierCode

CODE DEFINITION

1P Provider
2B Third-Party Administrator
36 Employer
80 Hospital
FA Facility

APRIL 2008 75
005010X279 • 270 • 2100B • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER NAME TECHNICAL REPORT • TYPE 3

GP Gateway Provider
P5 Plan Sponsor
PR Payer
REQUIRED NM102 1065 Entity Type Qualifier M1 ID 1/1
Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.

OD: 270B1_2100B_NM102__EntityTypeQualifier

300027 Use this code to indicate whether the entity is an individual person
or an organization.
CODE DEFINITION

1 Person
2 Non-Person Entity
REQUIRED NM103 1035 Name Last or Organization Name X1 AN 1/60
Individual last name or organizational name
SYNTAX: C1203

OD:
270B1_2100B_NM103__InformationReceiverLastorOrganizationName

IMPLEMENTATION NAME: Information Receiver Last or Organization Name

SITUATIONAL NM104 1036 Name First O 1 AN 1/35
Individual first name

300112 SITUATIONAL RULE: Required

when 2100B NM102 is “1". If not required
by this implementation guide, do not send.

OD: 270B1_2100B_NM104__InformationReceiverFirstName

IMPLEMENTATION NAME: Information Receiver First Name

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25

Individual middle name or initial

300350 SITUATIONAL RULE: Requiredwhen 2100B NM104 is present and Name

Suffix in 2100B NM107 if sent, are not sufficient to identify the
information receiver. If not required by this implementation guide
and NM104 is present, may be provided at sender’s discretion, but
cannot be required by the receiver.

OD: 270B1_2100B_NM105__InformationReceiverMiddleName

IMPLEMENTATION NAME: Information Receiver Middle Name

NOT USED NM106 1038 Name Prefix O 1 AN 1/10

76 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100B • NM1
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER NAME

SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10

Suffix to individual name

300037 SITUATIONAL RULE: Requiredwhen 2100B NM104 is present and Middle

Name in 2100B NM105 if sent, are not sufficient to identify the
information receiver. If not required by this implementation guide
and NM104 is present, may be provided at sender’s discretion, but
cannot be required by the receiver.

OD: 270B1_2100B_NM107__InformationReceiverNameSuffix

IMPLEMENTATION NAME: Information Receiver Name Suffix

300163 Use this only if NM102 is “1".

REQUIRED NM108 66 Identification Code Qualifier X1 ID 1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX: P0809

OD: 270B1_2100B_NM108__IdentificationCodeQualifier

300273 Use this element to qualify the identification number submitted in

NM109. This is the number that the information source associates
with the information receiver. Because only one number can be
submitted in NM109, the following hierarchy must be used.
Additional identifiers are to be placed in the REF segment. If the
information receiver is a provider and the National Provider ID is
mandated for use and the provider is a covered health care
provider under the mandate, code value “XX” must be used.
Otherwise, one of the following codes may be used with the
following hierarchy applied: Use the first code that applies: “SV”,
“PP”, “FI”, “34". The code ”SV" is recommended to be used prior
to the mandated use of the National Provider ID. If the information
receiver is a payer and the CMS National PlanID is mandated for
use, code value “XV” must be used, otherwise, use code value “PI”.
If the information receiver is an employer, use code value “24".
CODE DEFINITION

24 Employer’s Identification Number

300114 Use this code only when the 270/271 transaction
sets are used by an employer inquiring about
eligibility and benefits of their employees.
34 Social Security Number
300164 The social security number may not be used for any
Federally administered programs such as Medicare.
FI Federal Taxpayer’s Identification Number
PI Payor Identification
300115 Use this code only when the 270/271 transaction
sets are used between two payers.
PP Pharmacy Processor Number
SV Service Provider Number
300165 Use this code for the identification number assigned
by the information source to be used by the
information receiver in health care transactions.

APRIL 2008 77
005010X279 • 270 • 2100B • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER NAME TECHNICAL REPORT • TYPE 3

XV Centers for Medicare and Medicaid Services PlanID

CODE SOURCE 540: Centers for Medicare and Medicaid Services
PlanID
XX Centers for Medicare and Medicaid Services
National Provider Identifier
CODE SOURCE 537: Centers for Medicare & Medicaid Services
National Provider Identifier
REQUIRED NM109 67 Identification Code X1 AN 2/80
Code identifying a party or other code
SYNTAX: P0809

OD: 270B1_2100B_NM109__InformationReceiverIdentificationNumber

IMPLEMENTATION NAME: Information Receiver Identification Number

NOT USED NM110 706 Entity Relationship Code X1 ID 2/2

NOT USED NM111 98 Entity Identifier Code O1 ID 2/3
NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

78 APRIL 2008
 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100B • REF
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER ADDITIONAL IDENTIFICATION
REFERENCE INFORMATION 005010X279
INFORMATION• 270 • 2100B ADDITIONAL
RECEIVER • REF IDENTIFICATION
REF

SEGMENT DETAIL
083
300
REF - INFORMATION RECEIVER ADDITIONAL
IDENTIFICATION
X12 Segment Name: Reference Information
X12 Purpose: To specify identifying information
X12 Syntax: 1. R0203
At least one of REF02 or REF03 is required.
Loop: 2100B — INFORMATION RECEIVER NAME

Segment Repeat: 9

Usage: SITUATIONAL

51
03
30 Situational Rule: Required when the information in 2100B NM1 is not sufficient to identify
the information receiver. If not required by this implementation guide, may
be provided at sender’s discretion, but cannot be required by the receiver.

199
300 TR3 Notes: 1. Use this segment when needed to convey other or additional
identification numbers for the information receiver. The type of
reference number is determined by the qualifier in REF01. Only one
occurrence of each REF01 code value may be used in the 2100B loop.

077
300 TR3 Example: REF✽EO✽477563928~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

Reference Reference
✽ Description ✽ Reference
REF ✽
Ident Qual
✽
Ident Identifier ~
M1 ID 2/3 X1 AN 1/50 X1 AN 1/80 O1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED REF01 128 Reference Identification Qualifier M1 ID 2/3

Code qualifying the Reference Identification

OD: 270B1_2100B_REF01__ReferenceIdentificationQualifier

300039 Use this code to specify or qualify the type of reference number
that is following in REF02.

300398 Only one occurrence of each REF01 code value may be used in the
2100B loop.
CODE DEFINITION

0B State License Number

300269 The state assigning the license number must be
identified in REF03.
1C Medicare Provider Number
1D Medicaid Provider Number

APRIL 2008 79
005010X279 • 270 • 2100B • REF ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3

1J Facility ID Number
4A Personal Identification Number (PIN)
CT Contract Number
EL Electronic device pin number
EO Submitter Identification Number
HPI Centers for Medicare and Medicaid Services
National Provider Identifier
301101 The Centers for Medicare and Medicaid Services
National Provider Identifier may be used in this
segment prior to being mandated for use.
CODE SOURCE 537: Centers for Medicare & Medicaid Services
National Provider Identifier
JD User Identification
N5 Provider Plan Network Identification Number
N7 Facility Network Identification Number
Q4 Prior Identifier Number
SY Social Security Number
300164 The social security number may not be used for any
Federally administered programs such as Medicare.
TJ Federal Taxpayer’s Identification Number
REQUIRED REF02 127 Reference Identification X1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: R0203

OD: 270B1_2100B_REF02__InformationReceiverAdditionalIdentifier

IMPLEMENTATION NAME: Information Receiver Additional Identifier

300038 Use this reference number as qualified by the preceding data

element (REF01).
SITUATIONAL REF03 352 Description X1 AN 1/80
A free-form description to clarify the related data elements and their content
SYNTAX: R0203

300352 SITUATIONAL RULE: Required

when the identifier supplied in REF02 is the
State License Number. If not required by this implementation guide,
do not send.

OD:
270B1_2100B_REF03__InformationReceiverAdditionalIdentifierState

IMPLEMENTATION NAME: Information Receiver Additional Identifier State

300271 Use this element for the two character state ID of the state
assigning the identifier supplied in REF02. See Code source 22:
States and Outlying Areas of the U.S.

NOT USED REF04 C040 REFERENCE IDENTIFIER O1

80 APRIL 2008
 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100B • N3
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER ADDRESS
PARTY LOCATION 005010X279
INFORMATION• 270 • 2100B ADDRESS
RECEIVER • N3
N3

SEGMENT DETAIL
084
300
N3 - INFORMATION RECEIVER ADDRESS
X12 Segment Name: Party Location
X12 Purpose: To specify the location of the named party
Loop: 2100B — INFORMATION RECEIVER NAME

Segment Repeat: 1

Usage: SITUATIONAL

66
01
30 Situational Rule: Required when the information receiver is a provider who has multiple
locations and it is needed to identify the location relative to the request. If
not required by this implementation guide, may be provided at sender’s
discretion, but cannot be required by the receiver.

053
300 TR3 Example: N3✽201 PARK AVENUE✽SUITE 300~

DIAGRAM

N301 166 N302 166

Address Address
N3 ✽ Information
✽
Information ~
M1 AN 1/55 O1 AN 1/55

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N301 166 Address Information M 1 AN 1/55

Address information

OD: 270B1_2100B_N301__InformationReceiverAddressLine

IMPLEMENTATION NAME: Information Receiver Address Line

300040 Use this information for the first line of the address information.

SITUATIONAL N302 166 Address Information O 1 AN 1/55

Address information

300197 SITUATIONAL RULE: Required

when a second address line exists. If not
required by this implementation guide, do not send.

OD:
270B1_2100B_N302__InformationReceiverAdditionalAddressLine

IMPLEMENTATION NAME: Information Receiver Additional Address Line

APRIL 2008 81
 005010X279 • 270 • 2100B • N4 ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3
GEOGRAPHIC LOCATION 005010X279
INFORMATION• 270 • 2100B CITY,
RECEIVER • N4 STATE, ZIP CODE
N4

SEGMENT DETAIL
085
300
N4 - INFORMATION RECEIVER CITY, STATE,
ZIP CODE
X12 Segment Name: Geographic Location
X12 Purpose: To specify the geographic place of the named party
X12 Syntax: 1. E0207
Only one of N402 or N407 may be present.
2. C0605
If N406 is present, then N405 is required.
3. C0704
If N407 is present, then N404 is required.
Loop: 2100B — INFORMATION RECEIVER NAME

Segment Repeat: 1

Usage: SITUATIONAL

95
03
30 Situational Rule: Required when the information receiver is a provider who has multiple
locations and it is needed to identify the location relative to the request. If
not required by this implementation guide, may be provided at sender’s
discretion, but cannot be required by the receiver.

341
300 TR3 Example: N4✽KANSAS CITY✽MO✽64108~

DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310
City State or Postal Country Location Location
N4 ✽
Name
✽
Prov Code
✽
Code
✽
Code
✽
Qualifier
✽
Identifier
O1 AN 2/30 X1 ID 2/2 O1 ID 3/15 X1 ID 2/3 X1 ID 1/2 O1 AN 1/30

N407 1715

✽ Country Sub ~
Code
X1 ID 1/3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N401 19 City Name O 1 AN 2/30

Free-form text for city name
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.

OD: 270B1_2100B_N401__InformationReceiverCityName

IMPLEMENTATION NAME: Information Receiver City Name

82 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100B • N4
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER CITY, STATE, ZIP CODE

SITUATIONAL N402 156 State or Province Code X1 ID 2/2

Code (Standard State/Province) as defined by appropriate government agency
SYNTAX: E0207
COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

300304 SITUATIONAL RULE: Required

when address is in the United States of
America, including its territories, or Canada. If not required by this
implementation guide, do not send.

OD: 270B1_2100B_N402__InformationReceiverStateCode

IMPLEMENTATION NAME: Information Receiver State Code

CODE SOURCE 22: States and Provinces

SITUATIONAL N403 116 Postal Code O1 ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)

300342 SITUATIONAL RULE: Requiredwhen the address is in the United States of

America, including its territories, or Canada, or when a postal code
exists for the country in N404. If not required by this
implementation guide, do not send.

OD: 270B1_2100B_N403__InformationReceiverPostalZoneorZIPCode

IMPLEMENTATION NAME: Information Receiver Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes
SITUATIONAL N404 26 Country Code X1 ID 2/3
Code identifying the country
SYNTAX: C0704

300200 SITUATIONAL RULE: Required

when the address is outside the United
States of America. If not required by this implementation guide, do
not send.

OD: 270B1_2100B_N404__CountryCode

CODE SOURCE 5: Countries, Currencies and Funds

300343 Use the alpha-2 country codes from Part 1 of ISO 3166.

NOT USED N405 309 Location Qualifier X1 ID 1/2

NOT USED N406 310 Location Identifier O 1 AN 1/30
SITUATIONAL N407 1715 Country Subdivision Code X1 ID 1/3
Code identifying the country subdivision
SYNTAX: E0207, C0704

300344 SITUATIONAL RULE: Required when the address is not in the United
States of America, including its territories, or Canada, and the
country in N404 has administrative subdivisions such as but not
limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.

OD: 270B1_2100B_N407__CountrySubdivisionCode

CODE SOURCE 5: Countries, Currencies and Funds

300345 Use the country subdivision codes from Part 2 of ISO 3166.

APRIL 2008 83
 005010X279 • 270 • 2100B • PRV ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER PROVIDER INFORMATION TECHNICAL REPORT • TYPE 3
PROVIDER INFORMATION 005010X279
INFORMATION• 270 • 2100B PROVIDER
RECEIVER • PRV INFORMATION
PRV

SEGMENT DETAIL
086
300
PRV - INFORMATION RECEIVER PROVIDER
INFORMATION
X12 Segment Name: Provider Information
X12 Purpose: To specify the identifying characteristics of a provider
X12 Syntax: 1. P0203
If either PRV02 or PRV03 is present, then the other is required.
Loop: 2100B — INFORMATION RECEIVER NAME

Segment Repeat: 1

Usage: SITUATIONAL

33
01
30 Situational Rule: Required when the Information Receiver believes Provider Information is
relevant to the request and is necessary to convey the provider’s role in or
taxonomy code related to the eligibility/benefit being inquired about and
the provider is also the Information Receiver. If not required by this
implementation guide, may be provided at sender’s discretion, but cannot
be required by the receiver.

353
300 TR3 Notes: 1. For example, if the Information Receiver is also the Referring
Provider, this PRV segment would be used to identify the provider’s
role.

196
300 2. PRV02 qualifies PRV03.

399
300 TR3 Example: PRV✽RF✽PXC✽207Q00000X~

DIAGRAM

PRV01 1221 PRV02 128 PRV03 127 PRV04 156 PRV05 C035 PRV06 1223
Provider Reference Reference State or Provider Provider
PRV ✽ Code
✽
Ident Qual
✽
Ident
✽
Prov Code
✽
Spec. Inf.
✽
Org Code ~
M1 ID 1/3 X1 ID 2/3 X1 AN 1/50 O1 ID 2/2 O1 O1 ID 3/3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PRV01 1221 Provider Code M1 ID 1/3

Code identifying the type of provider

OD: 270B1_2100B_PRV01__ProviderCode

CODE DEFINITION

AD Admitting
AT Attending
BI Billing
CO Consulting
CV Covering
H Hospital

84 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100B • PRV
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER PROVIDER INFORMATION

HH Home Health Care

LA Laboratory
OT Other Physician
P1 Pharmacist
P2 Pharmacy
PC Primary Care Physician
PE Performing
R Rural Health Clinic
RF Referring
SB Submitting
SK Skilled Nursing Facility
SU Supervising
SITUATIONAL PRV02 128 Reference Identification Qualifier X1 ID 2/3
Code qualifying the Reference Identification
SYNTAX: P0203

300400 SITUATIONAL RULE: Required when the Information Receiver believes

Provider Information is relevant to the request and is necessary to
convey the provider’s taxonomy code in relation to the
eligibility/benefit being inquired about and the provider is also the
Information Receiver. If not required by this implementation guide,
may be provided at sender’s discretion, but cannot be required by
the receiver.

OD: 270B1_2100B_PRV02__ReferenceIdentificationQualifier

CODE DEFINITION

PXC Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy
SITUATIONAL PRV03 127 Reference Identification X1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: P0203

300400 SITUATIONAL RULE: Required when the Information Receiver believes

Provider Information is relevant to the request and is necessary to
convey the provider’s taxonomy code in relation to the
eligibility/benefit being inquired about and the provider is also the
Information Receiver. If not required by this implementation guide,
may be provided at sender’s discretion, but cannot be required by
the receiver.

OD: 270B1_2100B_PRV03__ReceiverProviderTaxonomyCode

IMPLEMENTATION NAME: Receiver Provider Taxonomy Code

NOT USED PRV04 156 State or Province Code O1 ID 2/2

NOT USED PRV05 C035 PROVIDER SPECIALTY INFORMATION O1
NOT USED PRV06 1223 Provider Organization Code O1 ID 3/3

APRIL 2008 85
 005010X279 • 270 • 2000C • HL ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER LEVEL TECHNICAL REPORT • TYPE 3
HIERARCHICAL LEVEL SUBSCRIBER
005010X279 • 270 • 2000C • HL
LEVEL
HL

SEGMENT DETAIL
092
300
HL - SUBSCRIBER LEVEL
X12 Segment Name: Hierarchical Level
X12 Purpose: To identify dependencies among and the content of hierarchically related
groups of data segments
X12 Comments: 1. The HL segment is used to identify levels of detail information using a
hierarchical structure, such as relating line-item data to shipment data, and
packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
Loop: 2000C — SUBSCRIBER LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: REQUIRED

390
300 TR3 Notes: 1. If the transaction set is to be used in a real time mode (see section
1.4.3 for additional detail), it is required that the 270 transaction
contain only one patient request (except as allowed in Section 1.4.3
Exceeding the Number of Patient Requests). One patient request (See
Section 1.4.2) is defined as the occurrence of one or more 2110 (EQ)
loops for an individual. If the patient is the subscriber, the patient
request is the existence of at least one 2110C loop. If the patient is the
dependent, the patient request is the existence of at least one 2110D
loop. In the event the patient has more than one occurrence of a 2110
(EQ) loop, that still constitutes one patient request.

If the transaction set is to be used in a batch mode (see section 1.4.3

for additional detail), it is required that the 270 transaction contain a
maximum of ninety-nine patient requests (except as allowed in
Section 1.4.3 Exceeding the Number of Patient Requests). One patient
request (See Section 1.4.2) is defined as the occurrence of one or
more 2110 (EQ) loops for an individual. If the patient is the subscriber,
the patient request is the existence of at least one 2110C loop. If the
patient is the dependent, the patient request is the existence of at
least one 2110D loop. In the event the patient has more than one
occurrence of a 2110 (EQ) loop, that still constitutes one patient
request.

Although it is not recommended, if the number of patients is to be

greater than one for real time mode or greater than ninety-nine for
batch mode, the trading partners (the Information Source, the
Information Receiver and the clearinghouse the transaction is routed
through, if there is one involved) must all agree to exceed the number
of patient requests and agree to a reasonable limit. See Section 1.4.3
Exceeding the Number of Patient Requests for additional information.

86 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2000C • HL
TECHNICAL REPORT • TYPE 3 SUBSCRIBER LEVEL

024
300 2. Use this segment to identify the hierarchical or entity level of
information being conveyed. The HL structure allows for the efficient
nesting of related occurrences of information. The developers’ intent
is to clearly identify the relationship of the patient to the subscriber
and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient)

can be grouped together under the same provider or the information
for multiple providers or information receivers can be grouped
together for the same payer or information source. See Section 1.3.2
for limitations on the number of occurrences of patients.

075
300 3. An example of the overall structure of the transaction set when used
in batch mode is:

Information Source (Loop 2000A)

Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry

052
300 TR3 Example: HL✽3✽2✽22✽1~

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736

Hierarch Hierarch Hierarch Hierarch
HL ✽ ID Number
✽
Parent ID
✽
Level Code
✽
Child Code
~
M1 AN 1/12 O1 AN 1/12 M1 ID 1/2 O1 ID 1/1

APRIL 2008 87
005010X279 • 270 • 2000C • HL ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER LEVEL TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HL01 628 Hierarchical ID Number M 1 AN 1/12

A unique number assigned by the sender to identify a particular data segment in
a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence
of the HL segment in the transaction set. For example, HL01 could be used to
indicate the number of occurrences of the HL segment, in which case the value of
HL01 would be “1" for the initial HL segment and would be incremented by one in
each subsequent HL segment within the transaction.

OD: 270B1_2000C_HL01__HierarchicalIDNumber

300031 Use this sequentially assigned positive number to identify each

specific occurrence of an HL segment within a transaction set. The
first HL segment in the transaction must begin with the number one
and be incremented by one for each successive occurrence of the
HL segment within that specific transaction set (ST through SE).

300116 An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~
HL*3*2*22*1~
NM1*IL*1*SMITH*ROBERT*B***MI*11122333301~
HL*4*3*23*0~
NM1*03*1*SMITH*MARY*LOU~
Eligibility/Benefit Data
HL*5*2*22*0~
NM1*IL*1*BROWN*JOHN*E***MI*22211333301~
Eligibility/Benefit Data
REQUIRED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12
Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which
the current HL segment is subordinate.

OD: 270B1_2000C_HL02__HierarchicalParentIDNumber

300316 Use this code to identify the specific Information Receiver to which
this Subscriber is subordinate.

88 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2000C • HL
TECHNICAL REPORT • TYPE 3 SUBSCRIBER LEVEL

REQUIRED HL03 735 Hierarchical Level Code M1 ID 1/2

Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the
current HL segment up to the next occurrence of an HL segment in the
transaction. For example, HL03 is used to indicate that subsequent segments in
the HL loop form a logical grouping of data referring to shipment, order, or item-
level information.

OD: 270B1_2000C_HL03__HierarchicalLevelCode

300317 All data that follows this HL segment is associated with the
Subscriber identified by the level code. This association continues
until the next occurrence of an HL segment.
CODE DEFINITION

22 Subscriber
REQUIRED HL04 736 Hierarchical Child Code O1 ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL
segments related to the current HL segment.

OD: 270B1_2000C_HL04__HierarchicalChildCode

300144 If there is a Loop 2000D (Dependent) level subordinate to the

current Loop 2000C, the value must be “1". If there is no Loop
2000D (Dependent) level subordinate to the current Loop 2000C,
the value must be ”0" (zero).
CODE DEFINITION

0 No Subordinate HL Segment in This Hierarchical

Structure.
1 Additional Subordinate HL Data Segment in This
Hierarchical Structure.

APRIL 2008 89
 005010X279 • 270 • 2000C • TRN ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER TRACE NUMBER TECHNICAL REPORT • TYPE 3
TRACE SUBSCRIBER
005010X279 • 270 • 2000C
TRACE • TRN
NUMBER
TRN

SEGMENT DETAIL
087
300
TRN - SUBSCRIBER TRACE NUMBER
X12 Segment Name: Trace
X12 Purpose: To uniquely identify a transaction to an application
X12 Set Notes: 1. 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.
Loop: 2000C — SUBSCRIBER LEVEL

Segment Repeat: 2

Usage: SITUATIONAL

54
03
30 Situational Rule: Required when information receiver or clearinghouse intends to use the
TRN segment as a tracing mechanism for the eligibility transaction and
the subscriber is the patient. If not required by this implementation guide,
do not send.

168
300 TR3 Notes: 1. The information receiver may assign one TRN segment in this loop if
the subscriber is the patient. A clearinghouse may assign one TRN
segment in this loop if the subscriber is the patient. See Section 1.4.6
Information Linkage.

307
300 2. This segment must not be used if the subscriber is not the patient.
See section 1.4.2. Basic Concepts.

167
300 3. Trace numbers assigned at the subscriber level are intended to allow
tracing of an eligibility/benefit transaction when the subscriber is the
patient.

169
300 TR3 Example: TRN✽1✽98175-012547✽9877281234✽RADIOLOGY~
TRN✽1✽109834652831✽9XYZCLEARH✽REALTIME~

DIAGRAM

TRN01 481 TRN02 127 TRN03 509 TRN04 127

Trace Type Reference
✽ Originating ✽ Reference
TRN ✽ Code
✽
Ident Company ID Ident ~
M1 ID 1/2 M1 AN 1/50 O1 AN 10/10 O1 AN 1/50

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED TRN01 481 Trace Type Code M1 ID 1/2

Code identifying which transaction is being referenced

OD: 270B1_2000C_TRN01__TraceTypeCode

CODE DEFINITION

1 Current Transaction Trace Numbers

90 APRIL 2008
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TECHNICAL REPORT • TYPE 3 SUBSCRIBER TRACE NUMBER

REQUIRED TRN02 127 Reference Identification M 1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SEMANTIC: TRN02 provides unique identification for the transaction.

OD: 270B1_2000C_TRN02__TraceNumber

IMPLEMENTATION NAME: Trace Number

300033 Use this number for the trace or reference number assigned by the
information receiver or clearinghouse.
REQUIRED TRN03 509 Originating Company Identifier O 1 AN 10/10
A unique identifier designating the company initiating the funds transfer
instructions, business transaction or assigning tracking reference identification.
SEMANTIC: TRN03 identifies an organization.

OD: 270B1_2000C_TRN03__TraceAssigningEntityIdentifier

IMPLEMENTATION NAME: Trace Assigning Entity Identifier

300034 Use this number for the identification number of the company that
assigned the trace or reference number specified in the previous
data element (TRN02).

300170 The first position must be either a “1" if an EIN is used, a ”3" if a
DUNS is used or a “9" if a user assigned identifier is used.
SITUATIONAL TRN04 127 Reference Identification O 1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SEMANTIC: TRN04 identifies a further subdivision within the organization.

300355 SITUATIONAL RULE: Required

when it is necessary to further identify a
specific component of the company identified in the previous data
element (TRN03). If not required by this implementation guide, do
not send.

OD: 270B1_2000C_TRN04__TraceAssigningEntityAdditionalIdentifier

IMPLEMENTATION NAME: Trace Assigning Entity Additional Identifier

300035 This information allows the originating company to further identify

a specific division or group within that organization that was
responsible for assigning the trace or reference number.

APRIL 2008 91
 005010X279 • 270 • 2100C • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER NAME TECHNICAL REPORT • TYPE 3
INDIVIDUAL OR ORGANIZATIONAL NAME 005010X279
SUBSCRIBER • 270
NAME• 2100C • NM1
NM1

SEGMENT DETAIL
088
300
NM1 - SUBSCRIBER NAME
X12 Segment Name: Individual or Organizational Name
X12 Purpose: To supply the full name of an individual or organizational entity
X12 Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
3. C1203
If NM112 is present, then NM103 is required.
Loop: 2100C — SUBSCRIBER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

066
300 TR3 Notes: 1. Use this segment to identify an entity by name and/or identification
number. Use this NM1 loop to identify the insured or subscriber.

171
300 2. Please refer to Section 1.4.8 Search Options for specific information
about how to identify an individual to an Information Source.

308
300 TR3 Example: NM1✽IL✽1✽SMITH✽JOHN✽L✽✽✽MI✽444115555~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038
Entity ID Entity Type Name Last/ Name Name Name
NM1 ✽ Code
✽
Qualifier
✽
Org Name
✽
First
✽
Middle
✽
Prefix
M1 ID 2/3 M1 ID 1/1 X1 AN 1/60 O1 AN 1/35 O1 AN 1/25 O1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

Name ID Code ID Entity Entity ID Name Last/
✽ ✽ ✽ ✽ ✽ ✽ ~
Suffix Qualifier Code Relat Code Code Org Name
O1 AN 1/10 X1 ID 1/2 X1 AN 2/80 X1 ID 2/2 O1 ID 2/3 O1 AN 1/60

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED NM101 98 Entity Identifier Code M1 ID 2/3

Code identifying an organizational entity, a physical location, property or an
individual

OD: 270B1_2100C_NM101__EntityIdentifierCode

CODE DEFINITION

IL Insured or Subscriber

92 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • NM1
TECHNICAL REPORT • TYPE 3 SUBSCRIBER NAME

REQUIRED NM102 1065 Entity Type Qualifier M1 ID 1/1

Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.

OD: 270B1_2100C_NM102__EntityTypeQualifier

300027 Use this code to indicate whether the entity is an individual person
or an organization.
CODE DEFINITION

1 Person
SITUATIONAL NM103 1035 Name Last or Organization Name X1 AN 1/60
Individual last name or organizational name
SYNTAX: C1203

301084 SITUATIONAL RULE: Requiredwhen the subscriber is the patient and the
information receiver is utilizing the Primary Search Option (See
Section 1.4.8).
OR
Required when the subscriber is the patient and the information
receiver is utilizing one of the Required Alternate Search Options
that require the Patient’s Last Name (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for
an Alternate Search Option supported by the Information Source
(See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100C_NM103__SubscriberLastName

IMPLEMENTATION NAME: Subscriber Last Name

300089 Use this name for the subscriber’s last name.

300401 Information sources cannot require subscriber’s suffix be sent as a

part of the subscriber’s last name.

SITUATIONAL NM104 1036 Name First O 1 AN 1/35

Individual first name

301080 SITUATIONAL RULE: Requiredwhen the subscriber is the patient and the
information receiver is utilizing the Primary Search Option (See
Section 1.4.8).
OR
Required when the subscriber is the patient and the information
receiver is utilizing one of the Required Alternate Search Options
that require the Patient’s First Name (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for
an Alternate Search Option supported by the Information Source
(See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100C_NM104__SubscriberFirstName

IMPLEMENTATION NAME: Subscriber First Name

300090 Use this name for the subscriber’s first name.

APRIL 2008 93
005010X279 • 270 • 2100C • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER NAME TECHNICAL REPORT • TYPE 3

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25

Individual middle name or initial

300357 SITUATIONAL RULE: Requiredwhen the information receiver believes this

is needed for an Alternate Search Option supported by the
Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100C_NM105__SubscriberMiddleNameorInitial

IMPLEMENTATION NAME: Subscriber Middle Name or Initial

300201 Use this name for the subscriber’s middle name or initial.
NOT USED NM106 1038 Name Prefix O 1 AN 1/10
SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10
Suffix to individual name

300357 SITUATIONAL RULE: Requiredwhen the information receiver believes this

is needed for an Alternate Search Option supported by the
Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100C_NM107__SubscriberNameSuffix

IMPLEMENTATION NAME: Subscriber Name Suffix

300202 Use this for the suffix to an individual’s name; e.g., Sr., Jr. or III.

94 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • NM1
TECHNICAL REPORT • TYPE 3 SUBSCRIBER NAME

SITUATIONAL NM108 66 Identification Code Qualifier X1 ID 1/2

Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX: P0809

301081 SITUATIONAL RULE: Requiredwhen either the subscriber or dependent is

the patient and the information receiver is utilizing the Primary
Search Option (See Section 1.4.8).
OR
Required when either the subscriber or dependent is the patient
and the information receiver is utilizing one of the Required
Alternate Search Options (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for
an Alternate Search Option supported by the Information Source
(See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100C_NM108__IdentificationCodeQualifier

300145 Use this element to qualify the identification number submitted in

NM109. This is the primary number that the information source
associates with the subscriber.
CODE DEFINITION

II Standard Unique Health Identifier for each Individual

in the United States
300402 Under the Health Insurance Portability and
Accountability Act of 1996, the Secretary of the
Department of Health and Human Services may
adopt a standard individual identifier for use in this
transaction.
MI Member Identification Number
300173 This code may only be used prior to the mandated
use of code “II”. This is the unique number the
payer or information source uses to identify the
insured (e.g., Health Insurance Claim Number,
Medicaid Recipient ID Number, HMO Member ID,
etc.).

APRIL 2008 95
005010X279 • 270 • 2100C • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER NAME TECHNICAL REPORT • TYPE 3

SITUATIONAL NM109 67 Identification Code X1 AN 2/80

Code identifying a party or other code
SYNTAX: P0809

301081 SITUATIONAL RULE: Requiredwhen either the subscriber or dependent is

the patient and the information receiver is utilizing the Primary
Search Option (See Section 1.4.8).
OR
Required when either the subscriber or dependent is the patient
and the information receiver is utilizing one of the Required
Alternate Search Options (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for
an Alternate Search Option supported by the Information Source
(See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100C_NM109__SubscriberPrimaryIdentifier

IMPLEMENTATION NAME: Subscriber Primary Identifier

300036 Use this reference number as qualified by the preceding data

element (NM108).
NOT USED NM110 706 Entity Relationship Code X1 ID 2/2
NOT USED NM111 98 Entity Identifier Code O1 ID 2/3
NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

96 APRIL 2008
 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • REF
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ADDITIONAL IDENTIFICATION
REFERENCE INFORMATION SUBSCRIBER
005010X279 • 270 • 2100C •IDENTIFICATION
ADDITIONAL REF
REF

SEGMENT DETAIL
091
300
REF - SUBSCRIBER ADDITIONAL
IDENTIFICATION
X12 Segment Name: Reference Information
X12 Purpose: To specify identifying information
X12 Syntax: 1. R0203
At least one of REF02 or REF03 is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 9

Usage: SITUATIONAL

57
03
30 Situational Rule: Required when the information receiver believes this is needed for an
Alternate Search Option supported by the Information Source (See
Section 1.4.8).
If not required by this implementation guide, do not send.

203
300 TR3 Notes: 1. Use this segment when needed to convey identification numbers
other than or in addition to the Member Identification Number. The
type of reference number is determined by the qualifier in REF01. Only
one occurrence of each REF01 code value may be used in the 2100C
loop.

146
300 2. Health Insurance Claim (HIC) Number or Medicaid Recipient
Identification Numbers are to be provided in the NM1 segment as a
Member Identification Number when it is the primary number an
information source knows a member by (such as for Medicare or
Medicaid). Do not use this segment for the Health Insurance Claim
(HIC) Number or Medicaid Recipient Identification Number unless they
are different from the Member Identification Number provided in the
NM1 segment.

174
300 3. Please refer to Section 1.4.8 Search Options for specific information
about how to identify an individual to an Information Source.

134
300 TR3 Example: REF✽1L✽660415~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

Reference Reference Description Reference
REF ✽ Ident Qual
✽
Ident
✽ ✽
Identifier ~
M1 ID 2/3 X1 AN 1/50 X1 AN 1/80 O1

APRIL 2008 97
005010X279 • 270 • 2100C • REF ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED REF01 128 Reference Identification Qualifier M1 ID 2/3

Code qualifying the Reference Identification

OD: 270B1_2100C_REF01__ReferenceIdentificationQualifier

300039 Use this code to specify or qualify the type of reference number
that is following in REF02.

300403 Only one occurrence of each REF01 code value may be used in the
2100C loop.
CODE DEFINITION

18 Plan Number
1L Group or Policy Number
300137 Use this code only if it cannot be determined if the
number is a Group Number or a Policy number. Use
codes “IG” or “6P” when they can be determined.
1W Member Identification Number
300175 Use only after the Unique Patient Identifier is
available and has been provided in the NM109, but
use of the UPI has not been mandated.
3H Case Number
300276 Uses this code to identify the Case Number
assigned to the subscriber by the information
source.
6P Group Number
CT Contract Number
300176 This code is to be used only to identify the
provider’s contract number of the provider identified
in the PRV segment of Loop 2100C. This code is
only to be used once the CMS National Provider
Identifier has been mandated for use, and must be
sent if required in the contract between the
Information Receiver identified in Loop 2100B and
the Information Source identified in Loop 2100A.
EA Medical Record Identification Number
EJ Patient Account Number
F6 Health Insurance Claim (HIC) Number
300147 See segment note 2.
GH Identification Card Serial Number
300148 Use this code when the Identification Card has a
number in addition to the Member Identification
Number or Identity Card Number. The Identification
Card Serial Number uniquely identifies the card
when multiple cards have been or will be issued to a
member (e.g., on a monthly basis, replacement
cards). This is particularly prevalent in the Medicaid
environment.

98 APRIL 2008
ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • REF
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ADDITIONAL IDENTIFICATION

HJ Identity Card Number

300149 Use this code when the Identity Card Number is
different than the Member Identification Number.
This is particularly prevalent in the Medicaid
environment.
IG Insurance Policy Number
N6 Plan Network Identification Number
NQ Medicaid Recipient Identification Number
300147 See segment note 2.
SY Social Security Number
300164 The social security number may not be used for any
Federally administered programs such as Medicare.
Y4 Agency Claim Number
300387 This code is only to be used when submitting an
eligibility request to a Property and Casualty payer.
Use this code to identify the Property and Casualty
Claim Number associated with the subscriber. This
code is not a HIPAA requirement as of this writing.
REQUIRED REF02 127 Reference Identification X1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: R0203

OD: 270B1_2100C_REF02__SubscriberSupplementalIdentifier

IMPLEMENTATION NAME: Subscriber Supplemental Identifier

300038 Use this reference number as qualified by the preceding data

element (REF01).
NOT USED REF03 352 Description X1 AN 1/80
NOT USED REF04 C040 REFERENCE IDENTIFIER O1

APRIL 2008 99
 005010X279 • 270 • 2100C • N3 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ADDRESS TECHNICAL REPORT • TYPE 3
PARTY LOCATION SUBSCRIBER
005010X279 • 270 • 2100C • N3
ADDRESS
N3

SEGMENT DETAIL
093
300
N3 - SUBSCRIBER ADDRESS
X12 Segment Name: Party Location
X12 Purpose: To specify the location of the named party
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

57
03
30 Situational Rule: Required when the information receiver believes this is needed for an
Alternate Search Option supported by the Information Source (See
Section 1.4.8).
If not required by this implementation guide, do not send.

058
300 TR3 Example: N3✽15197 BROADWAY AVENUE✽APT 215~

DIAGRAM

N301 166 N302 166

Address Address
N3 ✽ Information
✽
Information ~
M1 AN 1/55 O1 AN 1/55

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N301 166 Address Information M 1 AN 1/55

Address information

OD: 270B1_2100C_N301__SubscriberAddressLine

IMPLEMENTATION NAME: Subscriber Address Line

300040 Use this information for the first line of the address information.

SITUATIONAL N302 166 Address Information O 1 AN 1/55

Address information

300357 SITUATIONAL RULE: Requiredwhen the information receiver believes this

is needed for an Alternate Search Option supported by the
Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100C_N302__SubscriberAddressLine

IMPLEMENTATION NAME: Subscriber Address Line

300041 Use this information for the second line of the address information.

300239 Required if a second address line exists.

100 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • N4
TECHNICAL REPORT • TYPE 3 SUBSCRIBER CITY, STATE, ZIP CODE
GEOGRAPHIC LOCATION SUBSCRIBER
005010X279 • 270 • 2100C
CITY, STATE,• ZIP
N4 CODE
N4

SEGMENT DETAIL
094
300
N4 - SUBSCRIBER CITY, STATE, ZIP CODE
X12 Segment Name: Geographic Location
X12 Purpose: To specify the geographic place of the named party
X12 Syntax: 1. E0207
Only one of N402 or N407 may be present.
2. C0605
If N406 is present, then N405 is required.
3. C0704
If N407 is present, then N404 is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

96
03
30 Situational Rule: Required when the information receiver believes this is needed for an
Alternate Search Option supported by the Information Source (See
Section 1.4.8).
If not required by this implementation guide, do not send.

341
300 TR3 Example: N4✽KANSAS CITY✽MO✽64108~

DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310
City State or Postal Country Location Location
N4 ✽
Name
✽
Prov Code
✽
Code
✽
Code
✽
Qualifier
✽
Identifier
O1 AN 2/30 X1 ID 2/2 O1 ID 3/15 X1 ID 2/3 X1 ID 1/2 O1 AN 1/30

N407 1715

✽ Country Sub ~
Code
X1 ID 1/3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N401 19 City Name O 1 AN 2/30

Free-form text for city name
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.

OD: 270B1_2100C_N401__SubscriberCityName

IMPLEMENTATION NAME: Subscriber City Name

APRIL 2008 101

005010X279 • 270 • 2100C • N4 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL N402 156 State or Province Code X1 ID 2/2

Code (Standard State/Province) as defined by appropriate government agency
SYNTAX: E0207
COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

300304 SITUATIONAL RULE: Required

when address is in the United States of
America, including its territories, or Canada. If not required by this
implementation guide, do not send.

OD: 270B1_2100C_N402__SubscriberStateCode

IMPLEMENTATION NAME: Subscriber State Code

CODE SOURCE 22: States and Provinces

SITUATIONAL N403 116 Postal Code O1 ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)

300342 SITUATIONAL RULE: Requiredwhen the address is in the United States of

America, including its territories, or Canada, or when a postal code
exists for the country in N404. If not required by this
implementation guide, do not send.

OD: 270B1_2100C_N403__SubscriberPostalZoneorZIPCode

IMPLEMENTATION NAME: Subscriber Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes
SITUATIONAL N404 26 Country Code X1 ID 2/3
Code identifying the country
SYNTAX: C0704

300200 SITUATIONAL RULE: Required

when the address is outside the United
States of America. If not required by this implementation guide, do
not send.

OD: 270B1_2100C_N404__CountryCode

CODE SOURCE 5: Countries, Currencies and Funds

300343 Use the alpha-2 country codes from Part 1 of ISO 3166.

NOT USED N405 309 Location Qualifier X1 ID 1/2

NOT USED N406 310 Location Identifier O 1 AN 1/30
SITUATIONAL N407 1715 Country Subdivision Code X1 ID 1/3
Code identifying the country subdivision
SYNTAX: E0207, C0704

300344 SITUATIONAL RULE: Required when the address is not in the United
States of America, including its territories, or Canada, and the
country in N404 has administrative subdivisions such as but not
limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.

OD: 270B1_2100C_N407__CountrySubdivisionCode

CODE SOURCE 5: Countries, Currencies and Funds

300345 Use the country subdivision codes from Part 2 of ISO 3166.

102 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • PRV
TECHNICAL REPORT • TYPE 3 PROVIDER INFORMATION
PROVIDER INFORMATION • 270 • 2100C • PRV
005010X279INFORMATION
PROVIDER
PRV

SEGMENT DETAIL
135
300
PRV - PROVIDER INFORMATION
X12 Segment Name: Provider Information
X12 Purpose: To specify the identifying characteristics of a provider
X12 Syntax: 1. P0203
If either PRV02 or PRV03 is present, then the other is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

40
02
30 Situational Rule: Required when the information source is known to process this
information in creating a 271 response and the information receiver feels
it is necessary to identify a specific provider or to associate a specialty
type related to the service identified in the 2110C loop. If not required by
this implementation guide, may be provided at sender’s discretion, but
cannot be required by the receiver.

177
300 TR3 Notes: 1. This segment must not be used to identify the information receiver or
the information receiver’s specialty type, unless the information is
different from that sent in the 2100B loop.

204
300 2. If identifying a specific provider, use this segment to convey specific
information about a provider’s role in the eligibility/benefit being
inquired about when the provider is not the information receiver. For
example, if the information receiver is a hospital and a referring
provider must be identified, this is the segment where the referring
provider would be identified.

178
300 3. If identifying a specific provider, this segment contains reference
identification numbers, all of which may be used up until the time the
National Provider Identifier (NPI) is mandated for use. After the NPI is
mandated, only the code for National Provider Identifier may be used.

179
300 4. If identifying a type of specialty associated with the services identified
in loop 2110C, use code PXC in PRV02 and the appropriate code in
PRV03.

196
300 5. PRV02 qualifies PRV03.

180
300 TR3 Example: PRV✽RF✽EI✽9991234567~
PRV✽RF✽PXC✽207Q00000X~

DIAGRAM

PRV01 1221 PRV02 128 PRV03 127 PRV04 156 PRV05 C035 PRV06 1223
Provider Reference Reference State or Provider Provider
PRV ✽
Code
✽
Ident Qual
✽
Ident
✽
Prov Code
✽
Spec. Inf.
✽
Org Code ~
M1 ID 1/3 X1 ID 2/3 X1 AN 1/50 O1 ID 2/2 O1 O1 ID 3/3

APRIL 2008 103

005010X279 • 270 • 2100C • PRV ASC X12N • INSURANCE SUBCOMMITTEE
PROVIDER INFORMATION TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PRV01 1221 Provider Code M1 ID 1/3

Code identifying the type of provider

OD: 270B1_2100C_PRV01__ProviderCode

CODE DEFINITION

AD Admitting
AT Attending
BI Billing
CO Consulting
CV Covering
H Hospital
HH Home Health Care
LA Laboratory
OT Other Physician
P1 Pharmacist
P2 Pharmacy
PC Primary Care Physician
PE Performing
R Rural Health Clinic
RF Referring
SK Skilled Nursing Facility
SU Supervising

104 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • PRV
TECHNICAL REPORT • TYPE 3 PROVIDER INFORMATION

SITUATIONAL PRV02 128 Reference Identification Qualifier X1 ID 2/3

Code qualifying the Reference Identification
SYNTAX: P0203

300359 SITUATIONAL RULE: Requiredwhen the information source is known to

process this information in creating a 271 response and the
information receiver feels it is necessary to identify a specific
provider or to associate a specialty type related to the service
identified in the 2110C loop. If not required by this implementation
guide, may be provided at sender’s discretion, but cannot be
required by the receiver.

OD: 270B1_2100C_PRV02__ReferenceIdentificationQualifier

300205 If this segment is used to identify a specific provider and the

National Provider ID is mandated for use, code value “HPI” must be
used, otherwise one of the other code values may be used.

300206 If this segment is used to identify a type of specialty associated

with the services identified in loop 2110C, use code PXC.
CODE DEFINITION

9K Servicer
300113 Use this code for the identification number assigned
by the information source to be used by the
information receiver in health care transactions.
D3 National Council for Prescription Drug Programs
Pharmacy Number
CODE SOURCE 307: National Council for Prescription Drug
Programs Pharmacy Number
EI Employer’s Identification Number
HPI Centers for Medicare and Medicaid Services
National Provider Identifier
300181 Required value when identifying a specific provider
when the National Provider ID is mandated for use.
Otherwise, one of the other listed codes may be
used.
CODE SOURCE 537: Centers for Medicare & Medicaid Services
National Provider Identifier
PXC Health Care Provider Taxonomy Code
CODE SOURCE 682: Health Care Provider Taxonomy
SY Social Security Number
300164 The social security number may not be used for any
Federally administered programs such as Medicare.
TJ Federal Taxpayer’s Identification Number

APRIL 2008 105

005010X279 • 270 • 2100C • PRV ASC X12N • INSURANCE SUBCOMMITTEE
PROVIDER INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL PRV03 127 Reference Identification X1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: P0203

300241 SITUATIONAL RULE: Required

when PRV02 is used. If not required by this
implementation guide, do not send.

OD: 270B1_2100C_PRV03__ProviderIdentifier

IMPLEMENTATION NAME: Provider Identifier

300056 Use this reference number as qualified by the preceding data

element (PRV02).
NOT USED PRV04 156 State or Province Code O1 ID 2/2
NOT USED PRV05 C035 PROVIDER SPECIALTY INFORMATION O1
NOT USED PRV06 1223 Provider Organization Code O1 ID 3/3

106 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • DMG
TECHNICAL REPORT • TYPE 3 SUBSCRIBER DEMOGRAPHIC INFORMATION
DEMOGRAPHIC INFORMATION SUBSCRIBER
005010X279 • 270 • 2100C • DMG
DEMOGRAPHIC INFORMATION
DMG

SEGMENT DETAIL
108
300
DMG - SUBSCRIBER DEMOGRAPHIC
INFORMATION
X12 Segment Name: Demographic Information
X12 Purpose: To supply demographic information
X12 Syntax: 1. P0102
If either DMG01 or DMG02 is present, then the other is required.
2. P1011
If either DMG10 or DMG11 is present, then the other is required.
3. C1105
If DMG11 is present, then DMG05 is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

56
03
30 Situational Rule: Required when the subscriber is the patient and the information receiver
is utilizing the Primary Search Option (See Section 1.4.8).
OR
Required when the subscriber is the patient and the information receiver
is utilizing one of the Required Alternate Search Options that require the
Patient’s Date of Birth (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for an
Alternate Search Option supported by the Information Source (See
Section 1.4.8).
If not required by this implementation guide, do not send.

045
300 TR3 Notes: 1. Use this segment when needed to convey birth date or gender
demographic information for the subscriber.

174
300 2. Please refer to Section 1.4.8 Search Options for specific information
about how to identify an individual to an Information Source.

059
300 TR3 Example: DMG✽D8✽19430917✽M~

DIAGRAM

DMG01 1250 DMG02 1251 DMG03 1068 DMG04 1067 DMG05 C056 DMG06 1066

✽ Date Time ✽ Date Time Gender Marital Comp Race

✽ Citizenship
DMG Format Qual Period
✽
Code
✽
Status Code
✽
or Ethn Inf Status Code
X1 ID 2/3 X1 AN 1/35 O1 ID 1/1 O1 ID 1/1 X 10 O1 ID 1/2

DMG07 26 DMG08 659 DMG09 380 DMG10 1270 DMG11 1271

Country Basis of Quantity Code List Industry
✽ ✽ ✽ ✽ ✽ ~
Code Verif Code Qual Code Code
O1 ID 2/3 O1 ID 1/2 O1 R 1/15 X1 ID 1/3 X1 AN 1/30

APRIL 2008 107

005010X279 • 270 • 2100C • DMG ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER DEMOGRAPHIC INFORMATION TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

SITUATIONAL DMG01 1250 Date Time Period Format Qualifier X1 ID 2/3

Code indicating the date format, time format, or date and time format
SYNTAX: P0102

300356 SITUATIONAL RULE: Required when the subscriber is the patient and the
information receiver is utilizing the Primary Search Option (See
Section 1.4.8).
OR
Required when the subscriber is the patient and the information
receiver is utilizing one of the Required Alternate Search Options
that require the Patient’s Date of Birth (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for
an Alternate Search Option supported by the Information Source
(See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100C_DMG01__DateTimePeriodFormatQualifier

300047 Use this code to indicate the format of the date of birth that follows
in DMG02.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

SITUATIONAL DMG02 1251 Date Time Period X1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times
SYNTAX: P0102
SEMANTIC: DMG02 is the date of birth.

300356 SITUATIONAL RULE: Requiredwhen the subscriber is the patient and the
information receiver is utilizing the Primary Search Option (See
Section 1.4.8).
OR
Required when the subscriber is the patient and the information
receiver is utilizing one of the Required Alternate Search Options
that require the Patient’s Date of Birth (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for
an Alternate Search Option supported by the Information Source
(See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100C_DMG02__SubscriberBirthDate

IMPLEMENTATION NAME: Subscriber Birth Date

300242 Use this date for the date of birth of the subscriber.

108 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • DMG
TECHNICAL REPORT • TYPE 3 SUBSCRIBER DEMOGRAPHIC INFORMATION

SITUATIONAL DMG03 1068 Gender Code O1 ID 1/1

Code indicating the sex of the individual

300357 SITUATIONAL RULE: Requiredwhen the information receiver believes this

is needed for an Alternate Search Option supported by the
Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100C_DMG03__SubscriberGenderCode

IMPLEMENTATION NAME: Subscriber Gender Code

300150 Use this code to indicate the subscriber’s gender.

CODE DEFINITION

F Female
M Male
NOT USED DMG04 1067 Marital Status Code O1 ID 1/1
NOT USED DMG05 C056 COMPOSITE RACE OR ETHNICITY X
INFORMATION 10
NOT USED DMG06 1066 Citizenship Status Code O1 ID 1/2
NOT USED DMG07 26 Country Code O1 ID 2/3
NOT USED DMG08 659 Basis of Verification Code O1 ID 1/2
NOT USED DMG09 380 Quantity O1 R 1/15
NOT USED DMG10 1270 Code List Qualifier Code X1 ID 1/3
NOT USED DMG11 1271 Industry Code X1 AN 1/30

APRIL 2008 109

 005010X279 • 270 • 2100C • INS ASC X12N • INSURANCE SUBCOMMITTEE
MULTIPLE BIRTH SEQUENCE NUMBER TECHNICAL REPORT • TYPE 3
INSURED BENEFIT 005010X279
MULTIPLE • 270SEQUENCE
BIRTH • 2100C • INS
NUMBER
INS

SEGMENT DETAIL
277
300
INS - MULTIPLE BIRTH SEQUENCE NUMBER
X12 Segment Name: Insured Benefit
X12 Purpose: To provide benefit information on insured entities
X12 Syntax: 1. P1112
If either INS11 or INS12 is present, then the other is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

07
02
30 Situational Rule: Required when the information receiver believes it is necessary to identify
the birth sequence of the subscriber in the case of multiple births with the
same birth date for an Alternate Search Option supported by the
Information Source (See Section 1.4.8). If not required by this
implementation guide, do not send.

278
300 TR3 Notes: 1. This segment must not be used if the subscriber is not part of a
multiple birth.

110
300 TR3 Example: INS✽Y✽18✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽3~

DIAGRAM

INS01 1073 INS02 1069 INS03 875 INS04 1203 INS05 1216 INS06 C052

✽ Yes/No Cond ✽ Individual

✽ Maintenance ✽ Maintain Benefit
✽ Medicare
INS Resp Code Relat Code Type Code Reason Code
✽
Status Code Status Code
M1 ID 1/1 M1 ID 2/2 O1 ID 3/3 O1 ID 2/3 O1 ID 1/1 O1

INS07 1219 INS08 584 INS09 1220 INS10 1073 INS11 1250 INS12 1251

✽ COBRA Qual ✽ Employment ✽ Student

✽ Yes/No Cond ✽ Date Time ✽ Date Time
Event Code Status Code Status Code Resp Code Format Qual Period
O1 ID 1/2 O1 ID 2/2 O1 ID 1/1 O1 ID 1/1 X1 ID 2/3 X1 AN 1/35

INS13 1165 INS14 19 INS15 156 INS16 26 INS17 1470

Confident City State or Country Number
✽ ✽ ✽ ✽ ✽ ~
Code Name Prov Code Code
O1 ID 1/1 O1 AN 2/30 O1 ID 2/2 O1 ID 2/3 O1 N0 1/9

110 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • INS
TECHNICAL REPORT • TYPE 3 MULTIPLE BIRTH SEQUENCE NUMBER

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED INS01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: INS01 indicates status of the insured. A “Y” value indicates the insured
is a subscriber: an “N” value indicates the insured is a dependent.

OD: 270B1_2100C_INS01__InsuredIndicator

IMPLEMENTATION NAME: Insured Indicator

300279 The value Y is used to satisfy X12 syntax.

CODE DEFINITION

Y Yes
300285 The value Y is used to satisfy X12 syntax. This data
has no business purpose and must not be used to
indicate if the insured is a subscriber.
REQUIRED INS02 1069 Individual Relationship Code M1 ID 2/2
Code indicating the relationship between two individuals or entities

OD: 270B1_2100C_INS02__IndividualRelationshipCode

300280 The value 18 is used only to satisfy X12 syntax.

CODE DEFINITION

18 Self
300286 The value 18 is used to satisfy X12 syntax. This data
has no business purpose and must not be used to
indicate the Individual’s relationship to the insured.
NOT USED INS03 875 Maintenance Type Code O1 ID 3/3
NOT USED INS04 1203 Maintenance Reason Code O1 ID 2/3
NOT USED INS05 1216 Benefit Status Code O1 ID 1/1
NOT USED INS06 C052 MEDICARE STATUS CODE O1
NOT USED INS07 1219 Consolidated Omnibus Budget Reconciliation O1 ID 1/2
Act (COBRA) Qualifying
NOT USED INS08 584 Employment Status Code O1 ID 2/2
NOT USED INS09 1220 Student Status Code O1 ID 1/1
NOT USED INS10 1073 Yes/No Condition or Response Code O1 ID 1/1
NOT USED INS11 1250 Date Time Period Format Qualifier X1 ID 2/3
NOT USED INS12 1251 Date Time Period X1 AN 1/35
NOT USED INS13 1165 Confidentiality Code O1 ID 1/1
NOT USED INS14 19 City Name O 1 AN 2/30
NOT USED INS15 156 State or Province Code O1 ID 2/2
NOT USED INS16 26 Country Code O1 ID 2/3

APRIL 2008 111

005010X279 • 270 • 2100C • INS ASC X12N • INSURANCE SUBCOMMITTEE
MULTIPLE BIRTH SEQUENCE NUMBER TECHNICAL REPORT • TYPE 3

REQUIRED INS17 1470 Number O1 N0 1/9

A generic number
SEMANTIC: INS17 is the number assigned to each family member born with the
same birth date. This number identifies birth sequence for multiple births allowing
proper tracking and response of benefits for each dependent (i.e., twins, triplets,
etc.).

OD: 270B1_2100C_INS17__BirthSequenceNumber

IMPLEMENTATION NAME: Birth Sequence Number

300151 Use to indicate the birth order in the event of multiple births in
association with the birth date supplied in DMG02.

112 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • HI
TECHNICAL REPORT • TYPE 3 SUBSCRIBER HEALTH CARE DIAGNOSIS CODE
HEALTH CARE INFORMATION CODES 005010X279
SUBSCRIBER • 270 • 2100C
HEALTH • HIDIAGNOSIS CODE
CARE
HI

SEGMENT DETAIL
318
300
HI - SUBSCRIBER HEALTH CARE DIAGNOSIS
CODE
X12 Segment Name: Health Care Information Codes
X12 Purpose: To supply information related to the delivery of health care
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

60
03
30 Situational Rule: Required when the information receiver believes the Diagnosis
information is relevant to the inquiry, the information is available and if
the information source supports or is believed to support this level of
functionality. If not required by this implementation guide, do not send.

320
300 TR3 Notes: 1. Use the HI segment when an information source supports or may be
thought to support this level of functionality. If not supported, the
information source will process without this segment. The information
source must not use information in an HI segment of the 270
transaction in the determination of eligibility or benefits for the
subscriber if that information cannot be returned in the 271 response.

321
300 2. Use this segment to identify Diagnosis codes as they relate to the
information provided in the EQ segments.

322
300 3. Do not transmit the decimal points in the diagnosis codes. The
decimal point is assumed.

319
300 TR3 Example: HI✽BK:8901✽BF:87200✽BF:5559~

DIAGRAM

HI01 C022 HI02 C022 HI03 C022 HI04 C022 HI05 C022 HI06 C022

✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care
HI Code Info. Code Info. Code Info. Code Info. Code Info. Code Info.
M1 O1 O1 O1 O1 O1

HI07 C022 HI08 C022 HI09 C022 HI10 C022 HI11 C022 HI12 C022

✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ~
Code Info. Code Info. Code Info. Code Info. Code Info. Code Info.
O1 O1 O1 O1 O1 O1

APRIL 2008 113

005010X279 • 270 • 2100C • HI ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HI01 C022 HEALTH CARE CODE INFORMATION M1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

OD: 270B1_2100C_HI01_C022

300323 E codes are Not Used in HI01 except when defined by the claims
processor. E codes may be put in any other HI element using BF as
the qualifier.

300324 The diagnosis listed in this element is assumed to be the principal

diagnosis.
REQUIRED HI01 - 1 1270 Code List Qualifier Code M ID 1/3
Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100C_HI01_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABK International Classification of Diseases Clinical

Modification (ICD-10-CM) Principal Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BK International Classification of Diseases Clinical
Modification (ICD-9-CM) Principal Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI01 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100C_HI01_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI01 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI01 - 4 1251 Date Time Period X AN 1/35
NOT USED HI01 - 5 782 Monetary Amount O R 1/18
NOT USED HI01 - 6 380 Quantity O R 1/15
NOT USED HI01 - 7 799 Version Identifier O AN 1/30
NOT USED HI01 - 8 1271 Industry Code X AN 1/30
NOT USED HI01 - 9 1073 Yes/No Condition or Response Code X ID 1/1

114 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • HI
TECHNICAL REPORT • TYPE 3 SUBSCRIBER HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI02 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300404 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data element has been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100C_HI02_C022

REQUIRED HI02 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100C_HI02_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI02 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100C_HI02_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI02 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI02 - 4 1251 Date Time Period X AN 1/35
NOT USED HI02 - 5 782 Monetary Amount O R 1/18
NOT USED HI02 - 6 380 Quantity O R 1/15
NOT USED HI02 - 7 799 Version Identifier O AN 1/30
NOT USED HI02 - 8 1271 Industry Code X AN 1/30
NOT USED HI02 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 115

005010X279 • 270 • 2100C • HI ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI03 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100C_HI03_C022

REQUIRED HI03 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100C_HI03_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI03 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100C_HI03_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI03 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI03 - 4 1251 Date Time Period X AN 1/35
NOT USED HI03 - 5 782 Monetary Amount O R 1/18
NOT USED HI03 - 6 380 Quantity O R 1/15
NOT USED HI03 - 7 799 Version Identifier O AN 1/30
NOT USED HI03 - 8 1271 Industry Code X AN 1/30
NOT USED HI03 - 9 1073 Yes/No Condition or Response Code X ID 1/1

116 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • HI
TECHNICAL REPORT • TYPE 3 SUBSCRIBER HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI04 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100C_HI04_C022

REQUIRED HI04 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100C_HI04_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI04 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100C_HI04_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI04 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI04 - 4 1251 Date Time Period X AN 1/35
NOT USED HI04 - 5 782 Monetary Amount O R 1/18
NOT USED HI04 - 6 380 Quantity O R 1/15
NOT USED HI04 - 7 799 Version Identifier O AN 1/30
NOT USED HI04 - 8 1271 Industry Code X AN 1/30
NOT USED HI04 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 117

005010X279 • 270 • 2100C • HI ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI05 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100C_HI05_C022

REQUIRED HI05 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100C_HI05_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI05 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100C_HI05_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI05 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI05 - 4 1251 Date Time Period X AN 1/35
NOT USED HI05 - 5 782 Monetary Amount O R 1/18
NOT USED HI05 - 6 380 Quantity O R 1/15
NOT USED HI05 - 7 799 Version Identifier O AN 1/30
NOT USED HI05 - 8 1271 Industry Code X AN 1/30
NOT USED HI05 - 9 1073 Yes/No Condition or Response Code X ID 1/1

118 APRIL 2008

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TECHNICAL REPORT • TYPE 3 SUBSCRIBER HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI06 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100C_HI06_C022

REQUIRED HI06 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100C_HI06_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI06 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100C_HI06_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI06 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI06 - 4 1251 Date Time Period X AN 1/35
NOT USED HI06 - 5 782 Monetary Amount O R 1/18
NOT USED HI06 - 6 380 Quantity O R 1/15
NOT USED HI06 - 7 799 Version Identifier O AN 1/30
NOT USED HI06 - 8 1271 Industry Code X AN 1/30
NOT USED HI06 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 119

005010X279 • 270 • 2100C • HI ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI07 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100C_HI07_C022

REQUIRED HI07 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100C_HI07_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI07 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100C_HI07_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI07 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI07 - 4 1251 Date Time Period X AN 1/35
NOT USED HI07 - 5 782 Monetary Amount O R 1/18
NOT USED HI07 - 6 380 Quantity O R 1/15
NOT USED HI07 - 7 799 Version Identifier O AN 1/30
NOT USED HI07 - 8 1271 Industry Code X AN 1/30
NOT USED HI07 - 9 1073 Yes/No Condition or Response Code X ID 1/1

120 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100C • HI
TECHNICAL REPORT • TYPE 3 SUBSCRIBER HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI08 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100C_HI08_C022

REQUIRED HI08 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100C_HI08_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI08 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100C_HI08_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI08 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI08 - 4 1251 Date Time Period X AN 1/35
NOT USED HI08 - 5 782 Monetary Amount O R 1/18
NOT USED HI08 - 6 380 Quantity O R 1/15
NOT USED HI08 - 7 799 Version Identifier O AN 1/30
NOT USED HI08 - 8 1271 Industry Code X AN 1/30
NOT USED HI08 - 9 1073 Yes/No Condition or Response Code X ID 1/1
NOT USED HI09 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI10 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI11 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI12 C022 HEALTH CARE CODE INFORMATION O1

APRIL 2008 121

 005010X279 • 270 • 2100C • DTP ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER DATE TECHNICAL REPORT • TYPE 3
DATE OR TIME OR PERIOD SUBSCRIBER
005010X279 • 270
DATE• 2100C • DTP
DTP

SEGMENT DETAIL
095
300
DTP - SUBSCRIBER DATE
X12 Segment Name: Date or Time or Period
X12 Purpose: To specify any or all of a date, a time, or a time period
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 2

Usage: SITUATIONAL

61
03
30 Situational Rule: Required when the information receiver wishes to convey the plan date(s)
for the subscriber in relation to the eligibility/benefit inquiry. If not
required by this implementation guide, may be sent at the sender’s
discretion but cannot be required by the information source.
OR
Required when utilizing a search option other than the Primary Search
Option which requires the ID Card Issue Date. If not required by this
implementation guide, may be sent at the sender’s discretion but cannot
be required by the information source.

362
300 TR3 Notes: 1. Absence of a Plan date indicates the request is for the date the
transaction is processed and the information source is to process the
transaction in the same manner as if the processing date was sent.

326
300 2. Use this segment to convey the plan date(s) for the subscriber or for
the issue date of the subscriber’s identification card for the
information source.

139
300 3. When using code “291" (Plan) at this level, it is implied that these
dates apply to all of the Eligibility or Benefit Inquiry (EQ) loops that
follow. If there is a need to supply a different Plan date for a specific
EQ loop, it must be provided in the DTP segment within the EQ loop
and it will only apply to that EQ loop.

389
300 TR3 Example: DTP✽291✽D8✽20051015~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251

Date/Time
✽ Date Time ✽ Date Time
DTP ✽ Qualifier Format Qual Period
~
M1 ID 3/3 M1 ID 2/3 M1 AN 1/35

122 APRIL 2008

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TECHNICAL REPORT • TYPE 3 SUBSCRIBER DATE

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED DTP01 374 Date/Time Qualifier M1 ID 3/3

Code specifying type of date or time, or both date and time

OD: 270B1_2100C_DTP01__DateTimeQualifier

IMPLEMENTATION NAME: Date Time Qualifier

CODE DEFINITION

102 Issue
300182 Used if utilizing a search option other than the
Primary search option identified in section 1.4.8 and
is present on the identification card and is available.
291 Plan
REQUIRED DTP02 1250 Date Time Period Format Qualifier M1 ID 2/3
Code indicating the date format, time format, or date and time format
SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

OD: 270B1_2100C_DTP02__DateTimePeriodFormatQualifier

CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

RD8 Range of Dates Expressed in Format CCYYMMDD-
CCYYMMDD
REQUIRED DTP03 1251 Date Time Period M 1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times

OD: 270B1_2100C_DTP03__DateTimePeriod

300140 Use this date for the date(s) as qualified by the preceding data
elements.

APRIL 2008 123

 005010X279 • 270 • 2110C • EQ ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3
ELIGIBILITY OR BENEFIT INQUIRY 005010X279
SUBSCRIBER • 270 • 2110C OR
ELIGIBILITY • EQ
BENEFIT INQUIRY
EQ

SEGMENT DETAIL
289
300
EQ - SUBSCRIBER ELIGIBILITY OR BENEFIT
INQUIRY
X12 Segment Name: Eligibility or Benefit Inquiry
X12 Purpose: To specify inquired eligibility or benefit information
X12 Syntax: 1. R0102
At least one of EQ01 or EQ02 is required.
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY Loop
Repeat: 99

Segment Repeat: 1

Usage: SITUATIONAL

63
03
30 Situational Rule: Required when the subscriber is the patient whose eligibility or benefits
are being verified. If not required by this implementation guide, do not
send.

281
300 TR3 Notes: 1. When the subscriber is not the patient, the 2110C EQ segment must
not be used. When the transaction is used in a batch environment, it
is possible to have both 2110C and 2110D EQ segments when the
subscriber and dependent(s) are patients whose eligibility or benefits
are being verified. See Section 1.4.3 Batch and Real Time for
additional information.

282
300 2. The 2110C EQ segment begins the 2110C loop.

208
300 3. If the EQ segment is used, either EQ01 - Service Type Code or EQ02 -
Composite Medical Procedure Identifier must be used. Only EQ01 or
EQ02 is to be sent, not both.
An information source must support a generic request for Eligibility.
This is accomplished by submitting a Service Type Code of “30"
(Health Benefit Plan Coverage) in EQ01. An information source may
support the use of Service Type Codes other than ”30" (Health Benefit
Plan Coverage) in EQ01 at their discretion.
An information source may support the use of EQ02 - Composite
Medical Procedure Identifier at their discretion. The EQ02 allows for a
very specific inquiry, such as one based on a procedure code.
Additional information such as diagnosis codes can be supplied in
the 2100C HI segment and place of service in the 2110C III segment.

405
300 4. If an information source receives a Service Type Code “30" submitted
in the 270 EQ01 or a Service Type Code that they do not support, the
2110C EB03 values identified in Section 1.4.7.1 Item #8 must also be
returned if they are a covered benefit category at a plan level. Refer to
Section 1.4.7 for additional information.

124 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110C • EQ
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

283
300 5. EQ01 is a repeating data element that may be repeated up to 99 times.
If all of the information that will be used in the 2110C loop is the same
with the exception of the Service Type Code used in EQ01, it is more
efficient to use the repetition function of EQ01 to send each of the
Service Type Codes needed. If an Information Source supports more
than Service Type Code “30", and can support requests for multiple
Service Type Codes, the repetition use of EQ01 must be supported.

067
300 TR3 Example: EQ✽30✽✽FAM~

287
300 TR3 Example: EQ✽98^34^44^81^A0^A3~

DIAGRAM

EQ01 1365 EQ02 C003 EQ03 1207 EQ04 1336 EQ05 C004
Service Comp. Med. Coverage Insurance
✽ Comp. Diag.
EQ ✽ Type Code
✽
Proced. ID
✽
Level Code
✽
Type Code Code Point.
~
X 99 ID 1/2 X1 O1 ID 3/3 O1 ID 1/3 O1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

SITUATIONAL EQ01 1365 Service Type Code X ID 1/2

99
Code identifying the classification of service
SYNTAX: R0102
SEMANTIC: Position of data in the repeating data element conveys no significance.

300243 SITUATIONAL RULE: Required if utilizing a Service Type Code inquiry and
EQ02 is not used. If not required by this implementation guide, do
not send.

OD: 270B1_2110C_EQ01__ServiceTypeCode

300233 An information source must support a generic request for

Eligibility. This is accomplished by submitting a Service Type Code
of “30" (Health Benefit Plan Coverage) in EQ01.

300234 An information source may support the use of Service Type Codes
from the list other than “30" (Health Benefit Plan Coverage) in EQ01
at their discretion. If an information source supports codes in
addition to ”30", the information source may provide a list of the
supported codes from the list below to the information receiver. If
no list is provided, an information receiver may transmit the most
appropriate code.

300235 If an inquiry is submitted with a Service Type Code from the list
other than “30" and the information source does not support this
level of functionality, a generic response will be returned. The
generic response will be the same response as if a Service Type
Code of ”30" (Health Benefit Plan Coverage) was received by the
information source. Refer to Section 1.4.7 for additional information.

APRIL 2008 125

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SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3

300283 EQ01 is a repeating data element that may be repeated up to 99

times. If all of the information that will be used in the 2110C loop is
the same with the exception of the Service Type Code used in
EQ01, it is more efficient to use the repetition function of EQ01 to
send each of the Service Type Codes needed. If an Information
Source supports more than Service Type Code “30", and can
support requests for multiple Service Type Codes, the repetition
use of EQ01 must be supported.

300236 Not used if EQ02 is used.

CODE DEFINITION

1 Medical Care
2 Surgical
3 Consultation
4 Diagnostic X-Ray
5 Diagnostic Lab
6 Radiation Therapy
7 Anesthesia
8 Surgical Assistance
9 Other Medical
10 Blood Charges
11 Used Durable Medical Equipment
12 Durable Medical Equipment Purchase
13 Ambulatory Service Center Facility
14 Renal Supplies in the Home
15 Alternate Method Dialysis
16 Chronic Renal Disease (CRD) Equipment
17 Pre-Admission Testing
18 Durable Medical Equipment Rental
19 Pneumonia Vaccine
20 Second Surgical Opinion
21 Third Surgical Opinion
22 Social Work
23 Diagnostic Dental
24 Periodontics
25 Restorative
26 Endodontics
27 Maxillofacial Prosthetics
28 Adjunctive Dental Services
30 Health Benefit Plan Coverage
300120 If only a single category of inquiry can be
supported, use this code.
32 Plan Waiting Period
33 Chiropractic
34 Chiropractic Office Visits
35 Dental Care

126 APRIL 2008

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TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

36 Dental Crowns
37 Dental Accident
38 Orthodontics
39 Prosthodontics
40 Oral Surgery
41 Routine (Preventive) Dental
42 Home Health Care
43 Home Health Prescriptions
44 Home Health Visits
45 Hospice
46 Respite Care
47 Hospital
48 Hospital - Inpatient
49 Hospital - Room and Board
50 Hospital - Outpatient
51 Hospital - Emergency Accident
52 Hospital - Emergency Medical
53 Hospital - Ambulatory Surgical
54 Long Term Care
55 Major Medical
56 Medically Related Transportation
57 Air Transportation
58 Cabulance
59 Licensed Ambulance
60 General Benefits
61 In-vitro Fertilization
62 MRI/CAT Scan
63 Donor Procedures
64 Acupuncture
65 Newborn Care
66 Pathology
67 Smoking Cessation
68 Well Baby Care
69 Maternity
70 Transplants
71 Audiology Exam
72 Inhalation Therapy
73 Diagnostic Medical
74 Private Duty Nursing
75 Prosthetic Device
76 Dialysis
77 Otological Exam
78 Chemotherapy
79 Allergy Testing

APRIL 2008 127

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SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3

80 Immunizations
81 Routine Physical
82 Family Planning
83 Infertility
84 Abortion
85 AIDS
86 Emergency Services
87 Cancer
88 Pharmacy
89 Free Standing Prescription Drug
90 Mail Order Prescription Drug
91 Brand Name Prescription Drug
92 Generic Prescription Drug
93 Podiatry
94 Podiatry - Office Visits
95 Podiatry - Nursing Home Visits
96 Professional (Physician)
97 Anesthesiologist
98 Professional (Physician) Visit - Office
99 Professional (Physician) Visit - Inpatient
A0 Professional (Physician) Visit - Outpatient
A1 Professional (Physician) Visit - Nursing Home
A2 Professional (Physician) Visit - Skilled Nursing
Facility
A3 Professional (Physician) Visit - Home
A4 Psychiatric
A5 Psychiatric - Room and Board
A6 Psychotherapy
A7 Psychiatric - Inpatient
A8 Psychiatric - Outpatient
A9 Rehabilitation
AA Rehabilitation - Room and Board
AB Rehabilitation - Inpatient
AC Rehabilitation - Outpatient
AD Occupational Therapy
AE Physical Medicine
AF Speech Therapy
AG Skilled Nursing Care
AH Skilled Nursing Care - Room and Board
AI Substance Abuse
AJ Alcoholism
AK Drug Addiction
AL Vision (Optometry)
AM Frames

128 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110C • EQ
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

AN Routine Exam
300305 Use for Routine Vision Exam only.
AO Lenses
AQ Nonmedically Necessary Physical
AR Experimental Drug Therapy
B1 Burn Care
B2 Brand Name Prescription Drug - Formulary
B3 Brand Name Prescription Drug - Non-Formulary
BA Independent Medical Evaluation
BB Partial Hospitalization (Psychiatric)
BC Day Care (Psychiatric)
BD Cognitive Therapy
BE Massage Therapy
BF Pulmonary Rehabilitation
BG Cardiac Rehabilitation
BH Pediatric
BI Nursery
BJ Skin
BK Orthopedic
BL Cardiac
BM Lymphatic
BN Gastrointestinal
BP Endocrine
BQ Neurology
BR Eye
BS Invasive Procedures
BT Gynecological
BU Obstetrical
BV Obstetrical/Gynecological
BW Mail Order Prescription Drug: Brand Name
BX Mail Order Prescription Drug: Generic
BY Physician Visit - Office: Sick
BZ Physician Visit - Office: Well
C1 Coronary Care
CA Private Duty Nursing - Inpatient
CB Private Duty Nursing - Home
CC Surgical Benefits - Professional (Physician)
CD Surgical Benefits - Facility
CE Mental Health Provider - Inpatient
CF Mental Health Provider - Outpatient
CG Mental Health Facility - Inpatient
CH Mental Health Facility - Outpatient
CI Substance Abuse Facility - Inpatient
CJ Substance Abuse Facility - Outpatient

APRIL 2008 129

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SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3

CK Screening X-ray
CL Screening laboratory
CM Mammogram, High Risk Patient
CN Mammogram, Low Risk Patient
CO Flu Vaccination
CP Eyewear and Eyewear Accessories
CQ Case Management
DG Dermatology
DM Durable Medical Equipment
DS Diabetic Supplies
GF Generic Prescription Drug - Formulary
GN Generic Prescription Drug - Non-Formulary
GY Allergy
IC Intensive Care
MH Mental Health
NI Neonatal Intensive Care
ON Oncology
PT Physical Therapy
PU Pulmonary
RN Renal
RT Residential Psychiatric Treatment
TC Transitional Care
TN Transitional Nursery Care
UC Urgent Care
SITUATIONAL EQ02 C003 COMPOSITE MEDICAL PROCEDURE X1
IDENTIFIER
To identify a medical procedure by its standardized codes and applicable
modifiers

300364 SITUATIONAL RULE: Required if utilizing a Medical Procedure Code

inquiry when the information receiver believes that the information
source supports this high level of functionality and EQ01 is not
used. If not required by this implementation guide, do not send.

OD: 270B1_2110C_EQ02_C003

300209 An information source may support the use of EQ02 - Composite

Medical Procedure Identifier at their discretion. The EQ02 allows for
a very specific inquiry, such as one based on a procedure code.
Additional information such as diagnosis codes can be supplied in
the 2100C HI segment and place of service can be supplied in the
2110C III segment.

300210 If an inquiry is submitted with EQ02 and the information source

does not support this level of functionality, a generic response will
be returned. The generic response will be the same response as if a
Service Type Code of “30" (Health Benefit Plan Coverage) was
received by the information source. Refer to Section 1.4.7 for
additional information.

300211 Not used if EQ01 is used.

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TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

REQUIRED EQ02 - 1 235 Product/Service ID Qualifier M ID 2/2

Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
SEMANTIC:
C003-01 qualifies C003-02 and C003-08.

OD:
270B1_2110C_EQ02_C00301_ProductorServiceIDQualifier

IMPLEMENTATION NAME: Product or Service ID Qualifier

300152 Use this code to qualify the type of specific Product/Service

ID that will be used in EQ02-2.
CODE DEFINITION

AD American Dental Association Codes

CODE SOURCE 135: American Dental Association
CJ Current Procedural Terminology (CPT) Codes
CODE SOURCE 133: Current Procedural Terminology (CPT) Codes
HC Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
CODE SOURCE 130: Healthcare Common Procedure Coding
System
ID International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) -
Procedure
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
IV Home Infusion EDI Coalition (HIEC) Product/Service
Code
CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List
N4 National Drug Code in 5-4-2 Format
CODE SOURCE 240: National Drug Code by Format
ZZ Mutually Defined
300393 Use this code only for International Classification of
Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS).

CODE SOURCE 896: International Classification of

Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS)
REQUIRED EQ02 - 2 234 Product/Service ID M AN 1/48
Identifying number for a product or service
SEMANTIC:
If C003-08 is used, then C003-02 represents the beginning value in the
range in which the code occurs.

OD: 270B1_2110C_EQ02_C00302_ProcedureCode

IMPLEMENTATION NAME: Procedure Code

300117 Use this number for the product/service ID as identified by

the preceding data element (EQ02-1).

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SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3

SITUATIONAL EQ02 - 3 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-03 modifies the value in C003-02 and C003-08.

300365 SITUATIONAL RULE: Requiredwhen a modifier clarifies/improves

the accuracy of the associated procedure code, the modifier
is available and when the information receiver believes that
the information source supports this high level of
functionality. If not required by this implementation guide,
do not send.

OD: 270B1_2110C_EQ02_C00303_ProcedureModifier

300212 Used when an information source supports or may be

thought to support this high level of functionality if
modifiers are required to further specify the service. If not
supported, information source will process without this
data element.

SITUATIONAL EQ02 - 4 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-04 modifies the value in C003-02 and C003-08.

300366 SITUATIONAL RULE: Requiredwhen a second modifier

clarifies/improves the accuracy of the associated procedure
code, the modifier is available and when the information
receiver believes that the information source supports this
high level of functionality. If not required by this
implementation guide, do not send.

OD: 270B1_2110C_EQ02_C00304_ProcedureModifier

300212 Used when an information source supports or may be

thought to support this high level of functionality if
modifiers are required to further specify the service. If not
supported, information source will process without this
data element.

132 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110C • EQ
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

SITUATIONAL EQ02 - 5 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-05 modifies the value in C003-02 and C003-08.

300367 SITUATIONAL RULE: Requiredwhen a third modifier

clarifies/improves the accuracy of the associated procedure
code, the modifier is available and when the information
receiver believes that the information source supports this
high level of functionality. If not required by this
implementation guide, do not send.

OD: 270B1_2110C_EQ02_C00305_ProcedureModifier

300212 Used when an information source supports or may be

thought to support this high level of functionality if
modifiers are required to further specify the service. If not
supported, information source will process without this
data element.

SITUATIONAL EQ02 - 6 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-06 modifies the value in C003-02 and C003-08.

300368 SITUATIONAL RULE: Requiredwhen a fourth modifier

clarifies/improves the accuracy of the associated procedure
code, the modifier is available and when the information
receiver believes that the information source supports this
high level of functionality. If not required by this
implementation guide, do not send.

OD: 270B1_2110C_EQ02_C00306_ProcedureModifier

300212 Used when an information source supports or may be

thought to support this high level of functionality if
modifiers are required to further specify the service. If not
supported, information source will process without this
data element.

NOT USED EQ02 - 7 352 Description O AN 1/80

NOT USED EQ02 - 8 234 Product/Service ID O AN 1/48

APRIL 2008 133

005010X279 • 270 • 2110C • EQ ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3

SITUATIONAL EQ03 1207 Coverage Level Code O1 ID 3/3

Code indicating the level of coverage being provided for this insured

300391 SITUATIONAL RULE: Required

when the information receiver desires
coverage information for an entire family and believes that the
information source supports this functionality. If not required by
this implementation guide, do not send.

OD: 270B1_2110C_EQ03__CoverageLevelCode

300392 It is at the sole discretion of the information source whether to

support this functionality or not. If not supported, information
source will process without this data element.
CODE DEFINITION

FAM Family
NOT USED EQ04 1336 Insurance Type Code O1 ID 1/3
SITUATIONAL EQ05 C004 COMPOSITE DIAGNOSIS CODE POINTER O1
To identify one or more diagnosis code pointers

300327 SITUATIONAL RULE: Required when a 2100C HI segment is used. If not

required by this implementation guide, do not send.

OD: 270B1_2110C_EQ05_C004

REQUIRED EQ05 - 1 1328 Diagnosis Code Pointer M N0 1/2

A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-01 identifies the primary diagnosis code for this service line.

OD: 270B1_2110C_EQ05_C00401_DiagnosisCodePointer

300328 This first pointer designates the primary diagnosis for this
EQ segment. Remaining diagnosis pointers indicate
declining level of importance to the EQ segment.
Acceptable values are 1 through 8, and correspond to
Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100C.
SITUATIONAL EQ05 - 2 1328 Diagnosis Code Pointer O N0 1/2
A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-02 identifies the second diagnosis code for this service line.

300329 SITUATIONAL RULE: Required

when it is necessary to designate a
second diagnosis related to this EQ segment. If not
required by this implementation guide, do not send.

OD: 270B1_2110C_EQ05_C00402_DiagnosisCodePointer

300330 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100C.

134 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110C • EQ
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

SITUATIONAL EQ05 - 3 1328 Diagnosis Code Pointer O N0 1/2

A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-03 identifies the third diagnosis code for this service line.

300331 SITUATIONAL RULE: Required

when it is necessary to designate a
third diagnosis related to this EQ segment. If not required
by this implementation guide, do not send.

OD: 270B1_2110C_EQ05_C00403_DiagnosisCodePointer

300330 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100C.

SITUATIONAL EQ05 - 4 1328 Diagnosis Code Pointer O N0 1/2

A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-04 identifies the fourth diagnosis code for this service line.

300332 SITUATIONAL RULE: Required when it is necessary to designate a

fourth diagnosis related to this EQ segment. If not required
by this implementation guide, do not send.

OD: 270B1_2110C_EQ05_C00404_DiagnosisCodePointer

300330 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100C.

APRIL 2008 135

 005010X279 • 270 • 2110C • AMT ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER SPEND DOWN AMOUNT TECHNICAL REPORT • TYPE 3
MONETARY AMOUNT INFORMATION 005010X279
SUBSCRIBER • 270 • 2110C
SPEND DOWN• AMT
AMOUNT
AMT

SEGMENT DETAIL
125
300
AMT - SUBSCRIBER SPEND DOWN AMOUNT
X12 Segment Name: Monetary Amount Information
X12 Purpose: To indicate the total monetary amount
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

Segment Repeat: 1

Usage: SITUATIONAL

69
03
30 Situational Rule: Required if Spend Down amount is being reported. If not required by this
implementation guide, do not send.

213
300 TR3 Notes: 1. Use this segment only if it is necessary to report a Spend Down
amount. Under certain Medicaid programs, individuals must indicate
the dollar amount that they wish to apply towards their deductible.
These programs require individuals to pay a certain amount towards
their health care cost before Medicaid coverage starts.

074
300 TR3 Example: AMT✽R✽37.5~

DIAGRAM

AMT01 522 AMT02 782 AMT03 478

✽ Amount Qual ✽ Monetary Cred/Debit

AMT Code Amount
✽
Flag Code
~
M1 ID 1/3 M1 R 1/18 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED AMT01 522 Amount Qualifier Code M1 ID 1/3

Code to qualify amount

OD: 270B1_2110C_AMT01__AmountQualifierCode

CODE DEFINITION

R Spend Down
REQUIRED AMT02 782 Monetary Amount M1 R 1/18
Monetary amount

OD: 270B1_2110C_AMT02__SpendDownAmount

IMPLEMENTATION NAME: Spend Down Amount

300073 Use this monetary amount to specify the dollar amount associated
with this inquiry.
NOT USED AMT03 478 Credit/Debit Flag Code O1 ID 1/1

136 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110C • AMT
TECHNICAL REPORT • TYPE 3 SUBSCRIBER SPEND DOWN TOTAL BILLED AMOUNT
MONETARY AMOUNT INFORMATION 005010X279
SUBSCRIBER • 270 • 2110C
SPEND DOWN• AMT
TOTAL BILLED AMOUNT
AMT

SEGMENT DETAIL
370
300
AMT - SUBSCRIBER SPEND DOWN TOTAL
BILLED AMOUNT
X12 Segment Name: Monetary Amount Information
X12 Purpose: To indicate the total monetary amount
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

Segment Repeat: 1

Usage: SITUATIONAL

72
03
30 Situational Rule: Required if Spend Down amount is being reported in a separate 2110C
AMT segment and the information source also requires the Spend Down
Total Billed Amount. If not required by this implementation guide, do not
send.

373
300 TR3 Notes: 1. Use this segment only if it is necessary to report the Spend Down
Total Billed Amount in addition to the Spend Down Amount. See
2110C Subscriber Spend Down Amount segment for more information
about Spend Down.

371
300 TR3 Example: AMT✽PB✽37.5~

DIAGRAM

AMT01 522 AMT02 782 AMT03 478

✽ Amount Qual ✽ Monetary Cred/Debit

AMT Code Amount
✽
Flag Code ~
M1 ID 1/3 M1 R 1/18 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED AMT01 522 Amount Qualifier Code M1 ID 1/3

Code to qualify amount

OD: 270B1_2110C_AMT01__AmountQualifierCode

CODE DEFINITION

PB Billed Amount
REQUIRED AMT02 782 Monetary Amount M1 R 1/18
Monetary amount

OD: 270B1_2110C_AMT02__SpendDownTotalBilledAmount

IMPLEMENTATION NAME: Spend Down Total Billed Amount

300073 Use this monetary amount to specify the dollar amount associated
with this inquiry.
NOT USED AMT03 478 Credit/Debit Flag Code O1 ID 1/1

APRIL 2008 137

 005010X279 • 270 • 2110C • III ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INQUIRY INFORMATION TECHNICAL REPORT • TYPE 3
INFORMATION SUBSCRIBER
005010X279 • 270 • 2110C OR
ELIGIBILITY • III BENEFIT ADDITIONAL INQUIRY INFORMATION
III

SEGMENT DETAIL
183
300
III - SUBSCRIBER ELIGIBILITY OR BENEFIT
ADDITIONAL INQUIRY INFORMATION
X12 Segment Name: Information
X12 Purpose: To report information
X12 Syntax: 1. P0102
If either III01 or III02 is present, then the other is required.
2. L030405
If III03 is present, then at least one of III04 or III05 are required.
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

Segment Repeat: 1

Usage: SITUATIONAL

74
03
30 Situational Rule: Required when the information receiver believes the Facility Type
information is relevant to the inquiry and the information is available. If
not required by this implementation guide, do not send.

214
300 TR3 Notes: 1. Use the III segment when an information source supports or may be
thought to support this level of functionality. If not supported, the
information source will process without this segment.

394
300 TR3 Example: III✽ZZ✽21~

DIAGRAM

III01 1270 III02 1271 III03 1136 III04 933 III05 380 III06 C001
Code List Industry Code
✽ Free-Form ✽ Quantity Composite
III ✽ Qual Code
✽
Code
✽
Category Message Txt
✽
Unit of Mea
X1 ID 1/3 X1 AN 1/30 O1 ID 2/2 X1 AN 1/264 X1 R 1/15 O1

III07 752 III08 752 III09 752

Layer/Posit Layer/Posit Layer/Posit
✽ ✽ ✽ ~
Code Code Code
O1 ID 2/2 O1 ID 2/2 O1 ID 2/2

138 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110C • III
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INQUIRY INFORMATION

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED III01 1270 Code List Qualifier Code X1 ID 1/3

Code identifying a specific industry code list
SYNTAX: P0102

OD: 270B1_2110C_III01__CodeListQualifierCode

300185 Use this code to specify the code that is following in the III02 is a
Facility Type Code.
CODE DEFINITION

ZZ Mutually Defined
300215 Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of
Service Codes for Professional Claims.

APRIL 2008 139

005010X279 • 270 • 2110C • III ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INQUIRY INFORMATION TECHNICAL REPORT • TYPE 3

REQUIRED III02 1271 Industry Code X1 AN 1/30

Code indicating a code from a specific industry code list
SYNTAX: P0102

OD: 270B1_2110C_III02__IndustryCode

300186 Use this element for codes identifying a place of service from code
source 237. As a courtesy, the codes are listed below; however, the
code list is thought to be complete at the time of publication of this
implementation guideline. Since this list is subject to change, only
codes contained in the document available from code source 237
are to be supported in this transaction and take precedence over
any and all codes listed here.
01 Pharmacy
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-based Facility
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service
NOT USED III03 1136 Code Category O1 ID 2/2

140 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110C • III
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INQUIRY INFORMATION

NOT USED III04 933 Free-form Message Text X1 AN 1/264

NOT USED III05 380 Quantity X1 R 1/15
NOT USED III06 C001 COMPOSITE UNIT OF MEASURE O1
NOT USED III07 752 Surface/Layer/Position Code O1 ID 2/2
NOT USED III08 752 Surface/Layer/Position Code O1 ID 2/2
NOT USED III09 752 Surface/Layer/Position Code O1 ID 2/2

APRIL 2008 141

 005010X279 • 270 • 2110C • REF ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ADDITIONAL INFORMATION TECHNICAL REPORT • TYPE 3
REFERENCE INFORMATION SUBSCRIBER
005010X279 • 270 • 2110C •INFORMATION
ADDITIONAL REF
REF

SEGMENT DETAIL
096
300
REF - SUBSCRIBER ADDITIONAL
INFORMATION
X12 Segment Name: Reference Information
X12 Purpose: To specify identifying information
X12 Syntax: 1. R0203
At least one of REF02 or REF03 is required.
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

Segment Repeat: 1

Usage: SITUATIONAL

53
01
30 Situational Rule: Required when the subscriber has received a referral or prior
authorization number and the information receiver believes the
information is relevant to the inquiry (such as for a benefit or procedure
that requires a referral or prior authorization) and the information is
available. If not required by this implementation guide do not send.

244
300 TR3 Notes: 1. Use this segment when it is necessary to provide a referral or prior
authorization number for the benefit being inquired about.

062
300 TR3 Example: REF✽9F✽660415~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

Reference Reference
✽ Description ✽ Reference
REF ✽
Ident Qual
✽
Ident Identifier ~
M1 ID 2/3 X1 AN 1/50 X1 AN 1/80 O1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED REF01 128 Reference Identification Qualifier M1 ID 2/3

Code qualifying the Reference Identification

OD: 270B1_2110C_REF01__ReferenceIdentificationQualifier

300039 Use this code to specify or qualify the type of reference number
that is following in REF02.
CODE DEFINITION

9F Referral Number
G1 Prior Authorization Number

142 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110C • REF
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ADDITIONAL INFORMATION

REQUIRED REF02 127 Reference Identification X1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: R0203

OD: 270B1_2110C_REF02__PriorAuthorizationorReferralNumber

IMPLEMENTATION NAME: Prior Authorization or Referral Number

300038 Use this reference number as qualified by the preceding data

element (REF01).
NOT USED REF03 352 Description X1 AN 1/80
NOT USED REF04 C040 REFERENCE IDENTIFIER O1

APRIL 2008 143

 005010X279 • 270 • 2110C • DTP ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY/BENEFIT DATE TECHNICAL REPORT • TYPE 3
DATE OR TIME OR PERIOD SUBSCRIBER
005010X279 • 270 • 2110C • DTP
ELIGIBILITY/BENEFIT DATE
DTP

SEGMENT DETAIL
126
300
DTP - SUBSCRIBER ELIGIBILITY/BENEFIT
DATE
X12 Segment Name: Date or Time or Period
X12 Purpose: To specify any or all of a date, a time, or a time period
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

Segment Repeat: 1

Usage: SITUATIONAL

75
03
30 Situational Rule: Required when the plan date(s) are different from the date(s) provided in
the 2100C loop. If not required by this implementation guide, do not send.

118
300 TR3 Notes: 1. Use this segment to convey plan dates associated with the
information contained in the corresponding EQ segment.

187
300 2. This segment is only to be used to override dates provided in Loop
2100C when the date differs from the date provided in the DTP
segment in Loop 2100C. Dates that apply to the entire request must be
placed in the DTP segment in Loop 2100C. In order for a date to
appear here, there must be a date or a date range in the
corresponding 2100C loop.

245
300 TR3 Example: DTP✽291✽D8✽20051031~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251

Date/Time Date Time Date Time
DTP ✽
Qualifier
✽
Format Qual
✽
Period ~
M1 ID 3/3 M1 ID 2/3 M1 AN 1/35

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED DTP01 374 Date/Time Qualifier M1 ID 3/3

Code specifying type of date or time, or both date and time

OD: 270B1_2110C_DTP01__DateTimeQualifier

IMPLEMENTATION NAME: Date Time Qualifier

CODE DEFINITION

291 Plan

144 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110C • DTP
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY/BENEFIT DATE

REQUIRED DTP02 1250 Date Time Period Format Qualifier M1 ID 2/3

Code indicating the date format, time format, or date and time format
SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

OD: 270B1_2110C_DTP02__DateTimePeriodFormatQualifier

300043 Use this code to specify the format of the date(s) or time(s) that
follow in the next data element.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

RD8 Range of Dates Expressed in Format CCYYMMDD-
CCYYMMDD
REQUIRED DTP03 1251 Date Time Period M 1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times

OD: 270B1_2110C_DTP03__DateTimePeriod

300042 Use this date for the date(s) as qualified by the preceding data
elements.

APRIL 2008 145

 005010X279 • 270 • 2000D • HL ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT LEVEL TECHNICAL REPORT • TYPE 3
HIERARCHICAL LEVEL DEPENDENT• LEVEL
005010X279 270 • 2000D • HL
HL

SEGMENT DETAIL
097
300
HL - DEPENDENT LEVEL
X12 Segment Name: Hierarchical Level
X12 Purpose: To identify dependencies among and the content of hierarchically related
groups of data segments
X12 Comments: 1. The HL segment is used to identify levels of detail information using a
hierarchical structure, such as relating line-item data to shipment data, and
packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
Loop: 2000D — DEPENDENT LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: SITUATIONAL

76
03
30 Situational Rule: Required when the patient is a dependent of a member and cannot be
uniquely identified to the information source without the member’s
information in the Subscriber Level 2000C loop. If not required by this
implementation guide, do not send.

154
300 TR3 Notes: 1. If a patient is a dependent of a member, but can be uniquely identified
to the information source (such as by, but not limited to, a unique
Member Identification Number) then the patient is considered the
subscriber and is to be identified in the Subscriber Level.

188
300 2. Because the usage of this segment is “Situational”, this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix B for further details on ASC X12
nomenclature.

024
300 3. Use this segment to identify the hierarchical or entity level of
information being conveyed. The HL structure allows for the efficient
nesting of related occurrences of information. The developers’ intent
is to clearly identify the relationship of the patient to the subscriber
and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient)

can be grouped together under the same provider or the information
for multiple providers or information receivers can be grouped
together for the same payer or information source. See Section 1.3.2
for limitations on the number of occurrences of patients.

146 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2000D • HL
TECHNICAL REPORT • TYPE 3 DEPENDENT LEVEL

075
300 4. An example of the overall structure of the transaction set when used
in batch mode is:

Information Source (Loop 2000A)

Information Receiver (Loop 2000B)
Subscriber (Loop 2000C)
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
Subscriber (Loop 2000C)
Eligibility or Benefit Inquiry
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry

060
300 TR3 Example: HL✽4✽3✽23✽0~

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736

Hierarch Hierarch Hierarch Hierarch
HL ✽
ID Number
✽
Parent ID
✽
Level Code
✽
Child Code
~
M1 AN 1/12 O1 AN 1/12 M1 ID 1/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HL01 628 Hierarchical ID Number M 1 AN 1/12

A unique number assigned by the sender to identify a particular data segment in
a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence
of the HL segment in the transaction set. For example, HL01 could be used to
indicate the number of occurrences of the HL segment, in which case the value of
HL01 would be “1" for the initial HL segment and would be incremented by one in
each subsequent HL segment within the transaction.

OD: 270B1_2000D_HL01__HierarchicalIDNumber

300031 Use this sequentially assigned positive number to identify each

specific occurrence of an HL segment within a transaction set. The
first HL segment in the transaction must begin with the number one
and be incremented by one for each successive occurrence of the
HL segment within that specific transaction set (ST through SE).

300116 An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~
HL*3*2*22*1~
NM1*IL*1*SMITH*ROBERT*B***MI*11122333301~
HL*4*3*23*0~
NM1*03*1*SMITH*MARY*LOU~
Eligibility/Benefit Data
HL*5*2*22*0~
NM1*IL*1*BROWN*JOHN*E***MI*22211333301~
Eligibility/Benefit Data

APRIL 2008 147

005010X279 • 270 • 2000D • HL ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT LEVEL TECHNICAL REPORT • TYPE 3

REQUIRED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12

Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which
the current HL segment is subordinate.

OD: 270B1_2000D_HL02__HierarchicalParentIDNumber

300333 Use this code to identify the specific Subscriber to which this level
is subordinate.
REQUIRED HL03 735 Hierarchical Level Code M1 ID 1/2
Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the
current HL segment up to the next occurrence of an HL segment in the
transaction. For example, HL03 is used to indicate that subsequent segments in
the HL loop form a logical grouping of data referring to shipment, order, or item-
level information.

OD: 270B1_2000D_HL03__HierarchicalLevelCode

300334 All data that follows this HL segment is associated with the
Dependent identified by the level code. This association continues
until the next occurrence of an HL segment.
CODE DEFINITION

23 Dependent
REQUIRED HL04 736 Hierarchical Child Code O1 ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL
segments related to the current HL segment.

OD: 270B1_2000D_HL04__HierarchicalChildCode

300098 Because of the hierarchical structure, and because no HL level is

subordinate to this level, the code value in the HL04 at the Loop
2000D level must always be “0" (zero).
CODE DEFINITION

0 No Subordinate HL Segment in This Hierarchical

Structure.

148 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2000D • TRN
TECHNICAL REPORT • TYPE 3 DEPENDENT TRACE NUMBER
TRACE DEPENDENT• TRACE
005010X279 270 • 2000D • TRN
NUMBER
TRN

SEGMENT DETAIL
099
300
TRN - DEPENDENT TRACE NUMBER
X12 Segment Name: Trace
X12 Purpose: To uniquely identify a transaction to an application
X12 Set Notes: 1. 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.
Loop: 2000D — DEPENDENT LEVEL

Segment Repeat: 2

Usage: SITUATIONAL

77
03
30 Situational Rule: Required when information receiver or clearinghouse intends to use the
TRN segment as a tracing mechanism for the eligibility transaction and
the dependent is the patient. If not required by this implementation guide,
do not send.

189
300 TR3 Notes: 1. Trace numbers assigned at the dependent level are intended to allow
tracing of an eligibility/benefit transaction when the dependent is the
patient.

190
300 2. The information receiver may assign one TRN segment in this loop if
the dependent is the patient. A clearinghouse may assign one TRN
segment in this loop if the dependent is the patient. See Section 1.4.6
Information Linkage.

191
300 TR3 Example: TRN✽1✽98175-012547✽9877281234✽RADIOLOGY~
TRN✽1✽109834652831✽9XYZCLEARH✽REALTIME~

DIAGRAM

TRN01 481 TRN02 127 TRN03 509 TRN04 127

Trace Type Reference
✽ Originating ✽ Reference
TRN ✽ Code
✽
Ident Company ID Ident ~
M1 ID 1/2 M1 AN 1/50 O1 AN 10/10 O1 AN 1/50

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED TRN01 481 Trace Type Code M1 ID 1/2

Code identifying which transaction is being referenced

OD: 270B1_2000D_TRN01__TraceTypeCode

CODE DEFINITION

1 Current Transaction Trace Numbers

APRIL 2008 149

005010X279 • 270 • 2000D • TRN ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT TRACE NUMBER TECHNICAL REPORT • TYPE 3

REQUIRED TRN02 127 Reference Identification M 1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SEMANTIC: TRN02 provides unique identification for the transaction.

OD: 270B1_2000D_TRN02__TraceNumber

IMPLEMENTATION NAME: Trace Number

300033 Use this number for the trace or reference number assigned by the
information receiver or clearinghouse.
REQUIRED TRN03 509 Originating Company Identifier O 1 AN 10/10
A unique identifier designating the company initiating the funds transfer
instructions, business transaction or assigning tracking reference identification.
SEMANTIC: TRN03 identifies an organization.

OD: 270B1_2000D_TRN03__TraceAssigningEntityIdentifier

IMPLEMENTATION NAME: Trace Assigning Entity Identifier

300192 Use this number for the identification number of the company that
assigned the trace or reference number specified in the previous
data element (TRN02).

300170 The first position must be either a “1" if an EIN is used, a ”3" if a
DUNS is used or a “9" if a user assigned identifier is used.
SITUATIONAL TRN04 127 Reference Identification O 1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SEMANTIC: TRN04 identifies a further subdivision within the organization.

300355 SITUATIONAL RULE: Required

when it is necessary to further identify a
specific component of the company identified in the previous data
element (TRN03). If not required by this implementation guide, do
not send.

OD: 270B1_2000D_TRN04__TraceAssigningEntityAdditionalIdentifier

IMPLEMENTATION NAME: Trace Assigning Entity Additional Identifier

300035 This information allows the originating company to further identify

a specific division or group within that organization that was
responsible for assigning the trace or reference number.

150 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • NM1
TECHNICAL REPORT • TYPE 3 DEPENDENT NAME
INDIVIDUAL OR ORGANIZATIONAL NAME DEPENDENT• NAME
005010X279 270 • 2100D • NM1
NM1

SEGMENT DETAIL
100
300
NM1 - DEPENDENT NAME
X12 Segment Name: Individual or Organizational Name
X12 Purpose: To supply the full name of an individual or organizational entity
X12 Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
3. C1203
If NM112 is present, then NM103 is required.
Loop: 2100D — DEPENDENT NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

155
300 TR3 Notes: 1. Use this segment to identify an entity by name. This NM1 loop is used
to identify the dependent of an insured or subscriber.

174
300 2. Please refer to Section 1.4.8 Search Options for specific information
about how to identify an individual to an Information Source.

266
300 TR3 Example: NM1✽03✽1✽SMITH✽MARY LOU✽R~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038
Entity ID Entity Type Name Last/ Name Name Name
NM1 ✽ Code
✽
Qualifier
✽
Org Name
✽
First
✽
Middle
✽
Prefix
M1 ID 2/3 M1 ID 1/1 X1 AN 1/60 O1 AN 1/35 O1 AN 1/25 O1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

Name ID Code ID Entity Entity ID Name Last/
✽ ✽ ✽ ✽ ✽ ✽ ~
Suffix Qualifier Code Relat Code Code Org Name
O1 AN 1/10 X1 ID 1/2 X1 AN 2/80 X1 ID 2/2 O1 ID 2/3 O1 AN 1/60

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED NM101 98 Entity Identifier Code M1 ID 2/3

Code identifying an organizational entity, a physical location, property or an
individual

OD: 270B1_2100D_NM101__EntityIdentifierCode

CODE DEFINITION

03 Dependent

APRIL 2008 151

005010X279 • 270 • 2100D • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT NAME TECHNICAL REPORT • TYPE 3

REQUIRED NM102 1065 Entity Type Qualifier M1 ID 1/1

Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.

OD: 270B1_2100D_NM102__EntityTypeQualifier

300027 Use this code to indicate whether the entity is an individual person
or an organization.
CODE DEFINITION

1 Person
SITUATIONAL NM103 1035 Name Last or Organization Name X1 AN 1/60
Individual last name or organizational name
SYNTAX: C1203

300378 SITUATIONAL RULE: Requiredwhen the dependent is the patient and the
information receiver is utilizing the Primary Search Option (See
Section 1.4.8).
OR
Required when the dependent is the patient and the information
receiver is utilizing one of the Required Alternate Search Options
that require the Patient’s Last Name (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for
an Alternate Search Option supported by the Information Source
(See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100D_NM103__DependentLastName

IMPLEMENTATION NAME: Dependent Last Name

300101 Use this name for the dependent’s last name.

SITUATIONAL NM104 1036 Name First O 1 AN 1/35

Individual first name

301085 SITUATIONAL RULE: Required when the dependent is the patient and the
information receiver is utilizing the Primary Search Option (See
Section 1.4.8).
OR
Required when the dependent is the patient and the information
receiver is utilizing one of the Required Alternate Search Options
that require the Patient’s First Name (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for
an Alternate Search Option supported by the Information Source
(See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100D_NM104__DependentFirstName

IMPLEMENTATION NAME: Dependent First Name

300102 Use this name for the dependent’s first name.

152 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • NM1
TECHNICAL REPORT • TYPE 3 DEPENDENT NAME

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25

Individual middle name or initial

300357 SITUATIONAL RULE: Requiredwhen the information receiver believes this

is needed for an Alternate Search Option supported by the
Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100D_NM105__DependentMiddleName

IMPLEMENTATION NAME: Dependent Middle Name

300216 Use this name for the dependent’s middle name or initial.
NOT USED NM106 1038 Name Prefix O 1 AN 1/10
SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10
Suffix to individual name

300357 SITUATIONAL RULE: Requiredwhen the information receiver believes this

is needed for an Alternate Search Option supported by the
Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100D_NM107__DependentNameSuffix

IMPLEMENTATION NAME: Dependent Name Suffix

300217 Use this for the suffix to an individual’s name; e.g., Sr., Jr. or III.
NOT USED NM108 66 Identification Code Qualifier X1 ID 1/2
NOT USED NM109 67 Identification Code X1 AN 2/80
NOT USED NM110 706 Entity Relationship Code X1 ID 2/2
NOT USED NM111 98 Entity Identifier Code O1 ID 2/3
NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

APRIL 2008 153

 005010X279 • 270 • 2100D • REF ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3
REFERENCE INFORMATION DEPENDENT• ADDITIONAL
005010X279 270 • 2100D •IDENTIFICATION
REF
REF

SEGMENT DETAIL
103
300
REF - DEPENDENT ADDITIONAL
IDENTIFICATION
X12 Segment Name: Reference Information
X12 Purpose: To specify identifying information
X12 Syntax: 1. R0203
At least one of REF02 or REF03 is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 9

Usage: SITUATIONAL

57
03
30 Situational Rule: Required when the information receiver believes this is needed for an
Alternate Search Option supported by the Information Source (See
Section 1.4.8).
If not required by this implementation guide, do not send.

237
300 TR3 Notes: 1. Use this segment when needed to convey identification numbers for
the dependent. The type of reference number is determined by the
qualifier in REF01. Only one occurrence of each REF01 code value
may be used in the 2100D loop.

174
300 2. Please refer to Section 1.4.8 Search Options for specific information
about how to identify an individual to an Information Source.

136
300 TR3 Example: REF✽1L✽660415~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

Reference Reference Description Reference
REF ✽ Ident Qual
✽
Ident
✽ ✽
Identifier ~
M1 ID 2/3 X1 AN 1/50 X1 AN 1/80 O1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED REF01 128 Reference Identification Qualifier M1 ID 2/3

Code qualifying the Reference Identification

OD: 270B1_2100D_REF01__ReferenceIdentificationQualifier

300156 Use this code to specify or qualify the type of reference number
that is following in REF02.

300406 Only one occurrence of each REF01 code value may be used in the
2100D loop.
CODE DEFINITION

18 Plan Number

154 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • REF
TECHNICAL REPORT • TYPE 3 DEPENDENT ADDITIONAL IDENTIFICATION

1L Group or Policy Number

300137 Use this code only if it cannot be determined if the
number is a Group Number or a Policy number. Use
codes “IG” or “6P” when they can be determined.
6P Group Number
CT Contract Number
300193 This code is to be used only to identify the
provider’s contract number of the provider identified
in the PRV segment of Loop 2100D. This code is
only to be used once the CMS National Provider
Identifier has been mandated for use, and must be
sent if required in the contract between the
Information Receiver identified in Loop 2100B and
the Information Source identified in Loop 2100A.
EA Medical Record Identification Number
EJ Patient Account Number
F6 Health Insurance Claim (HIC) Number
GH Identification Card Serial Number
300157 Use this code when the Identification Card has a
number in addition to the Member Identification
Number or Identity Card Number. The Identification
Card Serial Number uniquely identifies the card
when multiple cards have been or will be issued to a
member (e.g., on a monthly basis, replacement
cards). This is particularly prevalent in the Medicaid
environment.
HJ Identity Card Number
300158 Use this code when the Identity Card Number is
different than the Member Identification Number.
This is particularly prevalent in the Medicaid
environment.
IF Issue Number
IG Insurance Policy Number
MRC Eligibility Category
CODE SOURCE 844: Eligibility Category
N6 Plan Network Identification Number
SY Social Security Number
300164 The social security number may not be used for any
Federally administered programs such as Medicare.
Y4 Agency Claim Number
300388 This code is to only be used when submitting an
eligibility request to a Property and Casualty payer.
Use this code to identify the Property and Casualty
Claim Number associated with the dependent. This
code is not a HIPAA requirement as of this writing.

APRIL 2008 155

005010X279 • 270 • 2100D • REF ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3

REQUIRED REF02 127 Reference Identification X1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: R0203

OD: 270B1_2100D_REF02__DependentSupplementalIdentifier

IMPLEMENTATION NAME: Dependent Supplemental Identifier

300038 Use this reference number as qualified by the preceding data

element (REF01).
NOT USED REF03 352 Description X1 AN 1/80
NOT USED REF04 C040 REFERENCE IDENTIFIER O1

156 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • N3
TECHNICAL REPORT • TYPE 3 DEPENDENT ADDRESS
PARTY LOCATION DEPENDENT• ADDRESS
005010X279 270 • 2100D • N3
N3

SEGMENT DETAIL
104
300
N3 - DEPENDENT ADDRESS
X12 Segment Name: Party Location
X12 Purpose: To specify the location of the named party
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

57
03
30 Situational Rule: Required when the information receiver believes this is needed for an
Alternate Search Option supported by the Information Source (See
Section 1.4.8).
If not required by this implementation guide, do not send.

058
300 TR3 Example: N3✽15197 BROADWAY AVENUE✽APT 215~

DIAGRAM

N301 166 N302 166

Address Address
N3 ✽ Information
✽
Information ~
M1 AN 1/55 O1 AN 1/55

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N301 166 Address Information M 1 AN 1/55

Address information

OD: 270B1_2100D_N301__DependentAddressLine

IMPLEMENTATION NAME: Dependent Address Line

300040 Use this information for the first line of the address information.

SITUATIONAL N302 166 Address Information O 1 AN 1/55

Address information

300357 SITUATIONAL RULE: Requiredwhen the information receiver believes this

is needed for an Alternate Search Option supported by the
Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100D_N302__DependentAddressLine

IMPLEMENTATION NAME: Dependent Address Line

300041 Use this information for the second line of the address information.

300239 Required if a second address line exists.

APRIL 2008 157

 005010X279 • 270 • 2100D • N4 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3
GEOGRAPHIC LOCATION DEPENDENT• CITY,
005010X279 270 • STATE,
2100D •ZIP
N4 CODE
N4

SEGMENT DETAIL
105
300
N4 - DEPENDENT CITY, STATE, ZIP CODE
X12 Segment Name: Geographic Location
X12 Purpose: To specify the geographic place of the named party
X12 Syntax: 1. E0207
Only one of N402 or N407 may be present.
2. C0605
If N406 is present, then N405 is required.
3. C0704
If N407 is present, then N404 is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

96
03
30 Situational Rule: Required when the information receiver believes this is needed for an
Alternate Search Option supported by the Information Source (See
Section 1.4.8).
If not required by this implementation guide, do not send.

341
300 TR3 Example: N4✽KANSAS CITY✽MO✽64108~

DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310
City State or Postal Country Location Location
N4 ✽
Name
✽
Prov Code
✽
Code
✽
Code
✽
Qualifier
✽
Identifier
O1 AN 2/30 X1 ID 2/2 O1 ID 3/15 X1 ID 2/3 X1 ID 1/2 O1 AN 1/30

N407 1715

✽ Country Sub ~
Code
X1 ID 1/3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N401 19 City Name O 1 AN 2/30

Free-form text for city name
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.

OD: 270B1_2100D_N401__DependentCityName

IMPLEMENTATION NAME: Dependent City Name

158 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • N4
TECHNICAL REPORT • TYPE 3 DEPENDENT CITY, STATE, ZIP CODE

SITUATIONAL N402 156 State or Province Code X1 ID 2/2

Code (Standard State/Province) as defined by appropriate government agency
SYNTAX: E0207
COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

300304 SITUATIONAL RULE: Required

when address is in the United States of
America, including its territories, or Canada. If not required by this
implementation guide, do not send.

OD: 270B1_2100D_N402__DependentStateCode

IMPLEMENTATION NAME: Dependent State Code

CODE SOURCE 22: States and Provinces

SITUATIONAL N403 116 Postal Code O1 ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)

300342 SITUATIONAL RULE: Requiredwhen the address is in the United States of

America, including its territories, or Canada, or when a postal code
exists for the country in N404. If not required by this
implementation guide, do not send.

OD: 270B1_2100D_N403__DependentPostalZoneorZIPCode

IMPLEMENTATION NAME: Dependent Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes
SITUATIONAL N404 26 Country Code X1 ID 2/3
Code identifying the country
SYNTAX: C0704

300200 SITUATIONAL RULE: Required

when the address is outside the United
States of America. If not required by this implementation guide, do
not send.

OD: 270B1_2100D_N404__CountryCode

CODE SOURCE 5: Countries, Currencies and Funds

300343 Use the alpha-2 country codes from Part 1 of ISO 3166.

NOT USED N405 309 Location Qualifier X1 ID 1/2

NOT USED N406 310 Location Identifier O 1 AN 1/30
SITUATIONAL N407 1715 Country Subdivision Code X1 ID 1/3
Code identifying the country subdivision
SYNTAX: E0207, C0704

300344 SITUATIONAL RULE: Required when the address is not in the United
States of America, including its territories, or Canada, and the
country in N404 has administrative subdivisions such as but not
limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.

OD: 270B1_2100D_N407__CountrySubdivisionCode

CODE SOURCE 5: Countries, Currencies and Funds

300345 Use the country subdivision codes from Part 2 of ISO 3166.

APRIL 2008 159

 005010X279 • 270 • 2100D • PRV ASC X12N • INSURANCE SUBCOMMITTEE
PROVIDER INFORMATION TECHNICAL REPORT • TYPE 3
PROVIDER INFORMATION • 270 • 2100D • PRV
005010X279INFORMATION
PROVIDER
PRV

SEGMENT DETAIL
238
300
PRV - PROVIDER INFORMATION
X12 Segment Name: Provider Information
X12 Purpose: To specify the identifying characteristics of a provider
X12 Syntax: 1. P0203
If either PRV02 or PRV03 is present, then the other is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

79
03
30 Situational Rule: Required when the information source is known to process this
information in creating a 271 response and the information receiver feels
it is necessary to identify a specific provider or to associate a specialty
type related to the service identified in the 2110D loop. If not required by
this implementation guide, may be provided at sender’s discretion, but
cannot be required by the receiver.

246
300 TR3 Notes: 1. This segment must not be used to identify the information receiver or
the information receiver’s specialty type, unless the information is
different from that sent in the 2100B loop.

218
300 2. If identifying a specific provider, use this segment to convey specific
information about a provider’s role in the eligibility/benefit being
inquired about when the provider is not the information receiver. For
example, if the information receiver is a hospital and a referring
provider must be identified, this is the segment where the referring
provider would be identified.

219
300 3. If identifying a specific provider, this segment contains reference
identification numbers, all of which may be used up until the time the
National Provider Identifier (NPI) is mandated for use. After the NPI is
mandated, only the code for National Provider Identifier may be used.

220
300 4. If identifying a type of specialty associated with the services identified
in loop 2110D, use code PXC in PRV02 and the appropriate code in
PRV03.

221
300 5. PRV02 qualifies PRV03.

180
300 TR3 Example: PRV✽RF✽EI✽9991234567~
PRV✽RF✽PXC✽207Q00000X~

DIAGRAM

PRV01 1221 PRV02 128 PRV03 127 PRV04 156 PRV05 C035 PRV06 1223
Provider Reference Reference State or Provider Provider
PRV ✽
Code
✽
Ident Qual
✽
Ident
✽
Prov Code
✽
Spec. Inf.
✽
Org Code ~
M1 ID 1/3 X1 ID 2/3 X1 AN 1/50 O1 ID 2/2 O1 O1 ID 3/3

160 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • PRV
TECHNICAL REPORT • TYPE 3 PROVIDER INFORMATION

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PRV01 1221 Provider Code M1 ID 1/3

Code identifying the type of provider

OD: 270B1_2100D_PRV01__ProviderCode

CODE DEFINITION

AD Admitting
AT Attending
BI Billing
CO Consulting
CV Covering
H Hospital
HH Home Health Care
LA Laboratory
OT Other Physician
P1 Pharmacist
P2 Pharmacy
PC Primary Care Physician
PE Performing
R Rural Health Clinic
RF Referring
SK Skilled Nursing Facility
SU Supervising

APRIL 2008 161

005010X279 • 270 • 2100D • PRV ASC X12N • INSURANCE SUBCOMMITTEE
PROVIDER INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL PRV02 128 Reference Identification Qualifier X1 ID 2/3

Code qualifying the Reference Identification
SYNTAX: P0203

300380 SITUATIONAL RULE: Requiredwhen the information source is known to

process this information in creating a 271 response and the
information receiver feels it is necessary to identify a specific
provider or to associate a specialty type related to the service
identified in the 2110D loop. If not required by this implementation
guide, may be provided at sender’s discretion, but cannot be
required by the receiver.

OD: 270B1_2100D_PRV02__ReferenceIdentificationQualifier

300222 If this segment is used to identify a specific provider and the

National Provider ID is mandated for use, code value “HPI” must be
used, otherwise one of the other code values may be used.

300267 If this segment is used to identify a type of specialty associated

with the services identified in loop 2110D, use code PXC.
CODE DEFINITION

9K Servicer
300113 Use this code for the identification number assigned
by the information source to be used by the
information receiver in health care transactions.
D3 National Council for Prescription Drug Programs
Pharmacy Number
CODE SOURCE 307: National Council for Prescription Drug
Programs Pharmacy Number
EI Employer’s Identification Number
HPI Centers for Medicare and Medicaid Services
National Provider Identifier
300181 Required value when identifying a specific provider
when the National Provider ID is mandated for use.
Otherwise, one of the other listed codes may be
used.
CODE SOURCE 537: Centers for Medicare & Medicaid Services
National Provider Identifier
PXC Health Care Provider Taxonomy Code
CODE SOURCE 682: Health Care Provider Taxonomy
SY Social Security Number
300164 The social security number may not be used for any
Federally administered programs such as Medicare.
TJ Federal Taxpayer’s Identification Number

162 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • PRV
TECHNICAL REPORT • TYPE 3 PROVIDER INFORMATION

SITUATIONAL PRV03 127 Reference Identification X1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: P0203

300241 SITUATIONAL RULE: Required

when PRV02 is used. If not required by this
implementation guide, do not send.

OD: 270B1_2100D_PRV03__ProviderIdentifier

IMPLEMENTATION NAME: Provider Identifier

300056 Use this reference number as qualified by the preceding data

element (PRV02).
NOT USED PRV04 156 State or Province Code O1 ID 2/2
NOT USED PRV05 C035 PROVIDER SPECIALTY INFORMATION O1
NOT USED PRV06 1223 Provider Organization Code O1 ID 3/3

APRIL 2008 163

 005010X279 • 270 • 2100D • DMG ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT DEMOGRAPHIC INFORMATION TECHNICAL REPORT • TYPE 3
DEMOGRAPHIC INFORMATION DEPENDENT• DEMOGRAPHIC
005010X279 270 • 2100D • DMG
INFORMATION
DMG

SEGMENT DETAIL
109
300
DMG - DEPENDENT DEMOGRAPHIC
INFORMATION
X12 Segment Name: Demographic Information
X12 Purpose: To supply demographic information
X12 Syntax: 1. P0102
If either DMG01 or DMG02 is present, then the other is required.
2. P1011
If either DMG10 or DMG11 is present, then the other is required.
3. C1105
If DMG11 is present, then DMG05 is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

82
10
30 Situational Rule: Required when the dependent is the patient and the information receiver
is utilizing the Primary Search Option (See Section 1.4.8).
OR
Required when the dependent is the patient and the information receiver
is utilizing one of the Required Alternate Search Options that require the
Patient’s Date of Birth (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for an
Alternate Search Option supported by the Information Source (See
Section 1.4.8).
If not required by this implementation guide, do not send.

119
300 TR3 Notes: 1. Use this segment when needed to convey the birth date or gender
demographic information for the dependent.

174
300 2. Please refer to Section 1.4.8 Search Options for specific information
about how to identify an individual to an Information Source.

106
300 TR3 Example: DMG✽D8✽19430121✽F~

DIAGRAM

DMG01 1250 DMG02 1251 DMG03 1068 DMG04 1067 DMG05 C056 DMG06 1066

✽ Date Time ✽ Date Time Gender Marital Comp Race

✽ Citizenship
DMG Format Qual Period
✽
Code
✽
Status Code
✽
or Ethn Inf Status Code
X1 ID 2/3 X1 AN 1/35 O1 ID 1/1 O1 ID 1/1 X 10 O1 ID 1/2

DMG07 26 DMG08 659 DMG09 380 DMG10 1270 DMG11 1271

Country Basis of Quantity Code List Industry
✽ ✽ ✽ ✽ ✽ ~
Code Verif Code Qual Code Code
O1 ID 2/3 O1 ID 1/2 O1 R 1/15 X1 ID 1/3 X1 AN 1/30

164 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • DMG
TECHNICAL REPORT • TYPE 3 DEPENDENT DEMOGRAPHIC INFORMATION

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

SITUATIONAL DMG01 1250 Date Time Period Format Qualifier X1 ID 2/3

Code indicating the date format, time format, or date and time format
SYNTAX: P0102

301082 SITUATIONAL RULE: Required when the dependent is the patient and the
information receiver is utilizing the Primary Search Option (See
Section 1.4.8).
OR
Required when the dependent is the patient and the information
receiver is utilizing one of the Required Alternate Search Options
that require the Patient’s Date of Birth (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for
an Alternate Search Option supported by the Information Source
(See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100D_DMG01__DateTimePeriodFormatQualifier

300047 Use this code to indicate the format of the date of birth that follows
in DMG02.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

SITUATIONAL DMG02 1251 Date Time Period X1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times
SYNTAX: P0102
SEMANTIC: DMG02 is the date of birth.

301082 SITUATIONAL RULE: Requiredwhen the dependent is the patient and the
information receiver is utilizing the Primary Search Option (See
Section 1.4.8).
OR
Required when the dependent is the patient and the information
receiver is utilizing one of the Required Alternate Search Options
that require the Patient’s Date of Birth (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for
an Alternate Search Option supported by the Information Source
(See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100D_DMG02__DependentBirthDate

IMPLEMENTATION NAME: Dependent Birth Date

300046 Use this date for the date of birth of the individual.

APRIL 2008 165

005010X279 • 270 • 2100D • DMG ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT DEMOGRAPHIC INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL DMG03 1068 Gender Code O1 ID 1/1

Code indicating the sex of the individual

300357 SITUATIONAL RULE: Requiredwhen the information receiver believes this

is needed for an Alternate Search Option supported by the
Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.

OD: 270B1_2100D_DMG03__DependentGenderCode

IMPLEMENTATION NAME: Dependent Gender Code

300159 Use this code to indicate the dependent’s gender.

CODE DEFINITION

F Female
M Male
NOT USED DMG04 1067 Marital Status Code O1 ID 1/1
NOT USED DMG05 C056 COMPOSITE RACE OR ETHNICITY X
INFORMATION 10
NOT USED DMG06 1066 Citizenship Status Code O1 ID 1/2
NOT USED DMG07 26 Country Code O1 ID 2/3
NOT USED DMG08 659 Basis of Verification Code O1 ID 1/2
NOT USED DMG09 380 Quantity O1 R 1/15
NOT USED DMG10 1270 Code List Qualifier Code X1 ID 1/3
NOT USED DMG11 1271 Industry Code X1 AN 1/30

166 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • INS
TECHNICAL REPORT • TYPE 3 DEPENDENT RELATIONSHIP
INSURED BENEFIT DEPENDENT• RELATIONSHIP
005010X279 270 • 2100D • INS
INS

SEGMENT DETAIL
127
300
INS - DEPENDENT RELATIONSHIP
X12 Segment Name: Insured Benefit
X12 Purpose: To provide benefit information on insured entities
X12 Syntax: 1. P1112
If either INS11 or INS12 is present, then the other is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

81
03
30 Situational Rule: Required when the information receiver believes it is necessary to identify
for an Alternate Search Option supported by the Information Source (See
Section 1.4.8) the dependent’s relationship to the insured and/or the birth
sequence of the dependent in the case of multiple births with the same
birth date. If not required by this implementation guide, do not send.

223
300 TR3 Notes: 1. Different types of health plans identify patients in different manners
depending upon how their eligibility is structured. However, two
approaches predominate.

The first approach is to assign each member of the family (and plan) a
unique ID number. This number can be used to identify and access
that individual’s information independent of whether he or she is a
child, spouse, or the actual subscriber to the plan. The relationship of
this individual to the actual subscriber or contract holder would be
one of spouse, child, self, etc.

The second approach is to assign the actual subscriber or contract

holder a unique ID number that is entered into the eligibility system.
Any related spouse, children, or dependents are identified through the
subscriber’s ID and have no unique identification number of their
own. In this approach, the subscriber would be identified at the Loop
2100C subscriber or insured level and the actual patient (spouse,
child, etc.) would be identified at the Loop 2100D dependent level
under the subscriber.

138
300 TR3 Example: INS✽N✽01~

APRIL 2008 167

005010X279 • 270 • 2100D • INS ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT RELATIONSHIP TECHNICAL REPORT • TYPE 3

DIAGRAM

INS01 1073 INS02 1069 INS03 875 INS04 1203 INS05 1216 INS06 C052

✽ Yes/No Cond ✽ Individual

✽ Maintenance ✽ Maintain Benefit
✽ Medicare
INS Resp Code Relat Code Type Code Reason Code
✽
Status Code Status Code
M1 ID 1/1 M1 ID 2/2 O1 ID 3/3 O1 ID 2/3 O1 ID 1/1 O1

INS07 1219 INS08 584 INS09 1220 INS10 1073 INS11 1250 INS12 1251

✽ COBRA Qual ✽ Employment ✽ Student

✽ Yes/No Cond ✽ Date Time ✽ Date Time
Event Code Status Code Status Code Resp Code Format Qual Period
O1 ID 1/2 O1 ID 2/2 O1 ID 1/1 O1 ID 1/1 X1 ID 2/3 X1 AN 1/35

INS13 1165 INS14 19 INS15 156 INS16 26 INS17 1470

Confident City State or Country Number
✽ ✽ ✽ ✽ ✽ ~
Code Name Prov Code Code
O1 ID 1/1 O1 AN 2/30 O1 ID 2/2 O1 ID 2/3 O1 N0 1/9

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED INS01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: INS01 indicates status of the insured. A “Y” value indicates the insured
is a subscriber: an “N” value indicates the insured is a dependent.

OD: 270B1_2100D_INS01__InsuredIndicator

IMPLEMENTATION NAME: Insured Indicator

CODE DEFINITION

N No
REQUIRED INS02 1069 Individual Relationship Code M1 ID 2/2
Code indicating the relationship between two individuals or entities

OD: 270B1_2100D_INS02__IndividualRelationshipCode

CODE DEFINITION

01 Spouse
19 Child
34 Other Adult
NOT USED INS03 875 Maintenance Type Code O1 ID 3/3
NOT USED INS04 1203 Maintenance Reason Code O1 ID 2/3
NOT USED INS05 1216 Benefit Status Code O1 ID 1/1
NOT USED INS06 C052 MEDICARE STATUS CODE O1
NOT USED INS07 1219 Consolidated Omnibus Budget Reconciliation O1 ID 1/2
Act (COBRA) Qualifying
NOT USED INS08 584 Employment Status Code O1 ID 2/2
NOT USED INS09 1220 Student Status Code O1 ID 1/1
NOT USED INS10 1073 Yes/No Condition or Response Code O1 ID 1/1
NOT USED INS11 1250 Date Time Period Format Qualifier X1 ID 2/3
NOT USED INS12 1251 Date Time Period X1 AN 1/35

168 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • INS
TECHNICAL REPORT • TYPE 3 DEPENDENT RELATIONSHIP

NOT USED INS13 1165 Confidentiality Code O1 ID 1/1

NOT USED INS14 19 City Name O 1 AN 2/30
NOT USED INS15 156 State or Province Code O1 ID 2/2
NOT USED INS16 26 Country Code O1 ID 2/3
SITUATIONAL INS17 1470 Number O1 N0 1/9
A generic number
SEMANTIC: INS17 is the number assigned to each family member born with the
same birth date. This number identifies birth sequence for multiple births allowing
proper tracking and response of benefits for each dependent (i.e., twins, triplets,
etc.).

300382 SITUATIONAL RULE: Required

when the information receiver believes it is
necessary to identify the birth sequence of the dependent in the
case of multiple births with the same birth date supplied in 2100
DMG02 for an Alternate Search Option supported by the
Information Source (See Section 1.4.8). If not required by this
implementation guide, do not send.

OD: 270B1_2100D_INS17__BirthSequenceNumber

IMPLEMENTATION NAME: Birth Sequence Number

APRIL 2008 169

 005010X279 • 270 • 2100D • HI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3
HEALTH CARE INFORMATION CODES DEPENDENT• HEALTH
005010X279 270 • 2100D
CARE• HI
DIAGNOSIS CODE
HI

SEGMENT DETAIL
335
300
HI - DEPENDENT HEALTH CARE DIAGNOSIS
CODE
X12 Segment Name: Health Care Information Codes
X12 Purpose: To supply information related to the delivery of health care
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

60
03
30 Situational Rule: Required when the information receiver believes the Diagnosis
information is relevant to the inquiry, the information is available and if
the information source supports or is believed to support this level of
functionality. If not required by this implementation guide, do not send.

337
300 TR3 Notes: 1. Use the HI segment when an information source supports or may be
thought to support this level of functionality. If not supported, the
information source will process without this segment. The information
source must not use information in an HI segment of the 270
transaction in the determination of eligibility or benefits for the
dependent if that information cannot be returned in the 271 response.

321
300 2. Use this segment to identify Diagnosis codes as they relate to the
information provided in the EQ segments.

322
300 3. Do not transmit the decimal points in the diagnosis codes. The
decimal point is assumed.

336
300 TR3 Example: HI✽BK:8901✽BF:87200✽BF:5559~

DIAGRAM

HI01 C022 HI02 C022 HI03 C022 HI04 C022 HI05 C022 HI06 C022

✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care
HI Code Info. Code Info. Code Info. Code Info. Code Info. Code Info.
M1 O1 O1 O1 O1 O1

HI07 C022 HI08 C022 HI09 C022 HI10 C022 HI11 C022 HI12 C022

✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ~
Code Info. Code Info. Code Info. Code Info. Code Info. Code Info.
O1 O1 O1 O1 O1 O1

170 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • HI
TECHNICAL REPORT • TYPE 3 DEPENDENT HEALTH CARE DIAGNOSIS CODE

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HI01 C022 HEALTH CARE CODE INFORMATION M1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

OD: 270B1_2100D_HI01_C022

300323 E codes are Not Used in HI01 except when defined by the claims
processor. E codes may be put in any other HI element using BF as
the qualifier.

300324 The diagnosis listed in this element is assumed to be the principal

diagnosis.
REQUIRED HI01 - 1 1270 Code List Qualifier Code M ID 1/3
Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100D_HI01_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABK International Classification of Diseases Clinical

Modification (ICD-10-CM) Principal Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BK International Classification of Diseases Clinical
Modification (ICD-9-CM) Principal Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI01 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100D_HI01_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI01 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI01 - 4 1251 Date Time Period X AN 1/35
NOT USED HI01 - 5 782 Monetary Amount O R 1/18
NOT USED HI01 - 6 380 Quantity O R 1/15
NOT USED HI01 - 7 799 Version Identifier O AN 1/30
NOT USED HI01 - 8 1271 Industry Code X AN 1/30
NOT USED HI01 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 171

005010X279 • 270 • 2100D • HI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI02 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300404 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data element has been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100D_HI02_C022

REQUIRED HI02 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100D_HI02_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI02 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100D_HI02_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI02 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI02 - 4 1251 Date Time Period X AN 1/35
NOT USED HI02 - 5 782 Monetary Amount O R 1/18
NOT USED HI02 - 6 380 Quantity O R 1/15
NOT USED HI02 - 7 799 Version Identifier O AN 1/30
NOT USED HI02 - 8 1271 Industry Code X AN 1/30
NOT USED HI02 - 9 1073 Yes/No Condition or Response Code X ID 1/1

172 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • HI
TECHNICAL REPORT • TYPE 3 DEPENDENT HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI03 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100D_HI03_C022

REQUIRED HI03 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100D_HI03_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI03 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100D_HI03_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI03 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI03 - 4 1251 Date Time Period X AN 1/35
NOT USED HI03 - 5 782 Monetary Amount O R 1/18
NOT USED HI03 - 6 380 Quantity O R 1/15
NOT USED HI03 - 7 799 Version Identifier O AN 1/30
NOT USED HI03 - 8 1271 Industry Code X AN 1/30
NOT USED HI03 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 173

005010X279 • 270 • 2100D • HI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI04 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100D_HI04_C022

REQUIRED HI04 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100D_HI04_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI04 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100D_HI04_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI04 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI04 - 4 1251 Date Time Period X AN 1/35
NOT USED HI04 - 5 782 Monetary Amount O R 1/18
NOT USED HI04 - 6 380 Quantity O R 1/15
NOT USED HI04 - 7 799 Version Identifier O AN 1/30
NOT USED HI04 - 8 1271 Industry Code X AN 1/30
NOT USED HI04 - 9 1073 Yes/No Condition or Response Code X ID 1/1

174 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • HI
TECHNICAL REPORT • TYPE 3 DEPENDENT HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI05 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100D_HI05_C022

REQUIRED HI05 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100D_HI05_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI05 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100D_HI05_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI05 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI05 - 4 1251 Date Time Period X AN 1/35
NOT USED HI05 - 5 782 Monetary Amount O R 1/18
NOT USED HI05 - 6 380 Quantity O R 1/15
NOT USED HI05 - 7 799 Version Identifier O AN 1/30
NOT USED HI05 - 8 1271 Industry Code X AN 1/30
NOT USED HI05 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 175

005010X279 • 270 • 2100D • HI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI06 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100D_HI06_C022

REQUIRED HI06 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100D_HI06_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI06 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100D_HI06_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI06 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI06 - 4 1251 Date Time Period X AN 1/35
NOT USED HI06 - 5 782 Monetary Amount O R 1/18
NOT USED HI06 - 6 380 Quantity O R 1/15
NOT USED HI06 - 7 799 Version Identifier O AN 1/30
NOT USED HI06 - 8 1271 Industry Code X AN 1/30
NOT USED HI06 - 9 1073 Yes/No Condition or Response Code X ID 1/1

176 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • HI
TECHNICAL REPORT • TYPE 3 DEPENDENT HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI07 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100D_HI07_C022

REQUIRED HI07 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100D_HI07_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI07 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100D_HI07_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI07 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI07 - 4 1251 Date Time Period X AN 1/35
NOT USED HI07 - 5 782 Monetary Amount O R 1/18
NOT USED HI07 - 6 380 Quantity O R 1/15
NOT USED HI07 - 7 799 Version Identifier O AN 1/30
NOT USED HI07 - 8 1271 Industry Code X AN 1/30
NOT USED HI07 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 177

005010X279 • 270 • 2100D • HI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI08 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300325 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 270B1_2100D_HI08_C022

REQUIRED HI08 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 270B1_2100D_HI08_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI08 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 270B1_2100D_HI08_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI08 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI08 - 4 1251 Date Time Period X AN 1/35
NOT USED HI08 - 5 782 Monetary Amount O R 1/18
NOT USED HI08 - 6 380 Quantity O R 1/15
NOT USED HI08 - 7 799 Version Identifier O AN 1/30
NOT USED HI08 - 8 1271 Industry Code X AN 1/30
NOT USED HI08 - 9 1073 Yes/No Condition or Response Code X ID 1/1
NOT USED HI09 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI10 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI11 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI12 C022 HEALTH CARE CODE INFORMATION O1

178 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2100D • DTP
TECHNICAL REPORT • TYPE 3 DEPENDENT DATE
DATE OR TIME OR PERIOD DEPENDENT• DATE
005010X279 270 • 2100D • DTP
DTP

SEGMENT DETAIL
128
300
DTP - DEPENDENT DATE
X12 Segment Name: Date or Time or Period
X12 Purpose: To specify any or all of a date, a time, or a time period
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 2

Usage: SITUATIONAL

83
03
30 Situational Rule: Required when the information receiver wishes to convey the plan date(s)
for the dependent in relation to the eligibility/benefit inquiry. If not
required by this implementation guide, may be sent at the sender’s
discretion but cannot be required by the information source.
OR
Required when utilizing a search option other than the Primary Search
Option which requires the ID Card Issue Date. If not required by this
implementation guide, may be sent at the sender’s discretion but cannot
be required by the information source.

362
300 TR3 Notes: 1. Absence of a Plan date indicates the request is for the date the
transaction is processed and the information source is to process the
transaction in the same manner as if the processing date was sent.

384
300 2. Use this segment to convey the plan date(s) for the dependent or for
the issue date of the dependent’s identification card for the
information source.

139
300 3. When using code “291" (Plan) at this level, it is implied that these
dates apply to all of the Eligibility or Benefit Inquiry (EQ) loops that
follow. If there is a need to supply a different Plan date for a specific
EQ loop, it must be provided in the DTP segment within the EQ loop
and it will only apply to that EQ loop.

389
300 TR3 Example: DTP✽291✽D8✽20051015~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251

Date/Time
✽ Date Time ✽ Date Time
DTP ✽ Qualifier Format Qual Period
~
M1 ID 3/3 M1 ID 2/3 M1 AN 1/35

APRIL 2008 179

005010X279 • 270 • 2100D • DTP ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT DATE TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED DTP01 374 Date/Time Qualifier M1 ID 3/3

Code specifying type of date or time, or both date and time

OD: 270B1_2100D_DTP01__DateTimeQualifier

IMPLEMENTATION NAME: Date Time Qualifier

CODE DEFINITION

102 Issue
300182 Used if utilizing a search option other than the
Primary search option identified in section 1.4.8 and
is present on the identification card and is available.
291 Plan
REQUIRED DTP02 1250 Date Time Period Format Qualifier M1 ID 2/3
Code indicating the date format, time format, or date and time format
SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

OD: 270B1_2100D_DTP02__DateTimePeriodFormatQualifier

300043 Use this code to specify the format of the date(s) or time(s) that
follow in the next data element.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

RD8 Range of Dates Expressed in Format CCYYMMDD-
CCYYMMDD
REQUIRED DTP03 1251 Date Time Period M 1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times

OD: 270B1_2100D_DTP03__DateTimePeriod

300042 Use this date for the date(s) as qualified by the preceding data
elements.

180 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110D • EQ
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY
ELIGIBILITY OR BENEFIT INQUIRY DEPENDENT• ELIGIBILITY
005010X279 270 • 2110DOR
• EQ
BENEFIT INQUIRY
EQ

SEGMENT DETAIL
408
300
EQ - DEPENDENT ELIGIBILITY OR BENEFIT
INQUIRY
X12 Segment Name: Eligibility or Benefit Inquiry
X12 Purpose: To specify inquired eligibility or benefit information
X12 Syntax: 1. R0102
At least one of EQ01 or EQ02 is required.
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY Loop
Repeat: 99

Segment Repeat: 1

Usage: REQUIRED

131
300 TR3 Notes: 1. Use this segment to begin the eligibility/benefit inquiry looping
structure.

268
300 2. If the EQ segment is used, either EQ01 - Service Type Code or EQ02 -
Composite Medical Procedure Identifier must be used. Only EQ01 or
EQ02 is to be sent, not both.

An information source must support a generic request for Eligibility.

This is accomplished by submitting a Service Type Code of “30"
(Health Benefit Plan Coverage) in EQ01. An information source may
support the use of Service Type Codes other than ”30" (Health Benefit
Plan Coverage) in EQ01 at their discretion.

An information source may support the use of EQ02 - Composite

Medical Procedure Identifier at their discretion. The EQ02 allows for a
very specific inquiry, such as one based on a procedure code.
Additional information such as diagnosis codes can be supplied in
the 2100D HI segment and place of service in the 2110D III segment.

288
300 3. If an information source receives a Service Type Code “30" submitted
in the 270 EQ01 or a Service Type Code that they do not support, the
2110D EB03 values identified in Section 1.4.7.1 Item #8 must also be
returned if they are a covered benefit category at a plan level. Refer to
Section 1.4.7 for additional information.

284
300 4. EQ01 is a repeating data element that may be repeated up to 99 times.
If all of the information that will be used in the 2110D loop is the same
with the exception of the Service Type Code used in EQ01, it is more
efficient to use the repetition function of EQ01 to send each of the
Service Type Codes needed. If an Information Source supports more
than Service Type Code “30", and can support requests for multiple
Service Type Codes, the repetition use of EQ01 must be supported.

287
300 TR3 Example: EQ✽98^34^44^81^A0^A3~

407
300 TR3 Example: EQ✽30~

APRIL 2008 181

005010X279 • 270 • 2110D • EQ ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3

DIAGRAM

EQ01 1365 EQ02 C003 EQ03 1207 EQ04 1336 EQ05 C004
Service Comp. Med. Coverage Insurance
✽ Comp. Diag.
EQ ✽ Type Code
✽
Proced. ID
✽
Level Code
✽
Type Code Code Point.
~
X 99 ID 1/2 X1 O1 ID 3/3 O1 ID 1/3 O1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

SITUATIONAL EQ01 1365 Service Type Code X ID 1/2

99
Code identifying the classification of service
SYNTAX: R0102
SEMANTIC: Position of data in the repeating data element conveys no significance.

300247 SITUATIONAL RULE: Required if utilizing a Service Type Code inquiry and
EQ02 is not used. If not required by this implementation guide, do
not send.

OD: 270B1_2110D_EQ01__ServiceTypeCode

300224 An information source must support a generic request for

Eligibility. This is accomplished by submitting a Service Type
Code of “30" (Health Benefit Plan Coverage) in EQ01.

300225 An information source may support the use of Service Type Codes
from the list other than “30" (Health Benefit Plan Coverage) in EQ01
at their discretion. If an information source supports codes in
addition to ”30", the information source may provide a list of the
supported codes from the list below to the information receiver. If
no list is provided, an information receiver may transmit the most
appropriate code.

300226 If an inquiry is submitted with a Service Type Code from the list
other than “30" and the information source does not support this
level of functionality, a generic response will be returned. The
generic response will be the same response as if a Service Type
Code of ”30" (Health Benefit Plan Coverage) was received by the
information source. Refer to Section 1.4.7 for additional information.

300284 EQ01 is a repeating data element that may be repeated up to 99

times. If all of the information that will be used in the 2110D loop is
the same with the exception of the Service Type Code used in
EQ01, it is more efficient to use the repetition function of EQ01 to
send each of the Service Type Codes needed. If an Information
Source supports more than Service Type Code “30", and can
support requests for multiple Service Type Codes, the repetition
use of EQ01 must be supported.

300227 Not used if EQ02 is used.

CODE DEFINITION

1 Medical Care
2 Surgical
3 Consultation

182 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110D • EQ
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

4 Diagnostic X-Ray
5 Diagnostic Lab
6 Radiation Therapy
7 Anesthesia
8 Surgical Assistance
9 Other Medical
10 Blood Charges
11 Used Durable Medical Equipment
12 Durable Medical Equipment Purchase
13 Ambulatory Service Center Facility
14 Renal Supplies in the Home
15 Alternate Method Dialysis
16 Chronic Renal Disease (CRD) Equipment
17 Pre-Admission Testing
18 Durable Medical Equipment Rental
19 Pneumonia Vaccine
20 Second Surgical Opinion
21 Third Surgical Opinion
22 Social Work
23 Diagnostic Dental
24 Periodontics
25 Restorative
26 Endodontics
27 Maxillofacial Prosthetics
28 Adjunctive Dental Services
30 Health Benefit Plan Coverage
300120 If only a single category of inquiry can be
supported, use this code.
32 Plan Waiting Period
33 Chiropractic
34 Chiropractic Office Visits
35 Dental Care
36 Dental Crowns
37 Dental Accident
38 Orthodontics
39 Prosthodontics
40 Oral Surgery
41 Routine (Preventive) Dental
42 Home Health Care
43 Home Health Prescriptions
44 Home Health Visits
45 Hospice
46 Respite Care
47 Hospital

APRIL 2008 183

005010X279 • 270 • 2110D • EQ ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3

48 Hospital - Inpatient
49 Hospital - Room and Board
50 Hospital - Outpatient
51 Hospital - Emergency Accident
52 Hospital - Emergency Medical
53 Hospital - Ambulatory Surgical
54 Long Term Care
55 Major Medical
56 Medically Related Transportation
57 Air Transportation
58 Cabulance
59 Licensed Ambulance
60 General Benefits
61 In-vitro Fertilization
62 MRI/CAT Scan
63 Donor Procedures
64 Acupuncture
65 Newborn Care
66 Pathology
67 Smoking Cessation
68 Well Baby Care
69 Maternity
70 Transplants
71 Audiology Exam
72 Inhalation Therapy
73 Diagnostic Medical
74 Private Duty Nursing
75 Prosthetic Device
76 Dialysis
77 Otological Exam
78 Chemotherapy
79 Allergy Testing
80 Immunizations
81 Routine Physical
82 Family Planning
83 Infertility
84 Abortion
85 AIDS
86 Emergency Services
87 Cancer
88 Pharmacy
89 Free Standing Prescription Drug
90 Mail Order Prescription Drug
91 Brand Name Prescription Drug

184 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110D • EQ
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

92 Generic Prescription Drug

93 Podiatry
94 Podiatry - Office Visits
95 Podiatry - Nursing Home Visits
96 Professional (Physician)
97 Anesthesiologist
98 Professional (Physician) Visit - Office
99 Professional (Physician) Visit - Inpatient
A0 Professional (Physician) Visit - Outpatient
A1 Professional (Physician) Visit - Nursing Home
A2 Professional (Physician) Visit - Skilled Nursing
Facility
A3 Professional (Physician) Visit - Home
A4 Psychiatric
A5 Psychiatric - Room and Board
A6 Psychotherapy
A7 Psychiatric - Inpatient
A8 Psychiatric - Outpatient
A9 Rehabilitation
AA Rehabilitation - Room and Board
AB Rehabilitation - Inpatient
AC Rehabilitation - Outpatient
AD Occupational Therapy
AE Physical Medicine
AF Speech Therapy
AG Skilled Nursing Care
AH Skilled Nursing Care - Room and Board
AI Substance Abuse
AJ Alcoholism
AK Drug Addiction
AL Vision (Optometry)
AM Frames
AN Routine Exam
300305 Use for Routine Vision Exam only.
AO Lenses
AQ Nonmedically Necessary Physical
AR Experimental Drug Therapy
B1 Burn Care
B2 Brand Name Prescription Drug - Formulary
B3 Brand Name Prescription Drug - Non-Formulary
BA Independent Medical Evaluation
BB Partial Hospitalization (Psychiatric)
BC Day Care (Psychiatric)
BD Cognitive Therapy

APRIL 2008 185

005010X279 • 270 • 2110D • EQ ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3

BE Massage Therapy
BF Pulmonary Rehabilitation
BG Cardiac Rehabilitation
BH Pediatric
BI Nursery
BJ Skin
BK Orthopedic
BL Cardiac
BM Lymphatic
BN Gastrointestinal
BP Endocrine
BQ Neurology
BR Eye
BS Invasive Procedures
BT Gynecological
BU Obstetrical
BV Obstetrical/Gynecological
BW Mail Order Prescription Drug: Brand Name
BX Mail Order Prescription Drug: Generic
BY Physician Visit - Office: Sick
BZ Physician Visit - Office: Well
C1 Coronary Care
CA Private Duty Nursing - Inpatient
CB Private Duty Nursing - Home
CC Surgical Benefits - Professional (Physician)
CD Surgical Benefits - Facility
CE Mental Health Provider - Inpatient
CF Mental Health Provider - Outpatient
CG Mental Health Facility - Inpatient
CH Mental Health Facility - Outpatient
CI Substance Abuse Facility - Inpatient
CJ Substance Abuse Facility - Outpatient
CK Screening X-ray
CL Screening laboratory
CM Mammogram, High Risk Patient
CN Mammogram, Low Risk Patient
CO Flu Vaccination
CP Eyewear and Eyewear Accessories
CQ Case Management
DG Dermatology
DM Durable Medical Equipment
DS Diabetic Supplies
GF Generic Prescription Drug - Formulary
GN Generic Prescription Drug - Non-Formulary

186 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110D • EQ
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

GY Allergy
IC Intensive Care
MH Mental Health
NI Neonatal Intensive Care
ON Oncology
PT Physical Therapy
PU Pulmonary
RN Renal
RT Residential Psychiatric Treatment
TC Transitional Care
TN Transitional Nursery Care
UC Urgent Care
SITUATIONAL EQ02 C003 COMPOSITE MEDICAL PROCEDURE X1
IDENTIFIER
To identify a medical procedure by its standardized codes and applicable
modifiers

300364 SITUATIONAL RULE: Requiredif utilizing a Medical Procedure Code

inquiry when the information receiver believes that the information
source supports this high level of functionality and EQ01 is not
used. If not required by this implementation guide, do not send.

OD: 270B1_2110D_EQ02_C003

300385 An information source may support the use of EQ02 - Composite

Medical Procedure Identifier at their discretion. The EQ02 allows for
a very specific inquiry, such as one based on a procedure code.
Additional information such as diagnosis codes can be supplied in
the 2100D HI segment and place of service can be supplied in the
2110D III segment.

300228 If an inquiry is submitted with EQ02 and the information source

does not support this level of functionality, a generic response will
be returned. The generic response will be the same response as if a
Service Type Code of “30" (Health Benefit Plan Coverage) was
received by the information source. Refer to Section 1.4.7 for
additional information.

300229 Not used if EQ01 is used.

APRIL 2008 187

005010X279 • 270 • 2110D • EQ ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3

REQUIRED EQ02 - 1 235 Product/Service ID Qualifier M ID 2/2

Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
SEMANTIC:
C003-01 qualifies C003-02 and C003-08.

OD:
270B1_2110D_EQ02_C00301_ProductorServiceIDQualifier

IMPLEMENTATION NAME: Product or Service ID Qualifier

300160 Use this code to qualify the type of specific Product/Service

ID that will be used in EQ02-2.
CODE DEFINITION

AD American Dental Association Codes

CODE SOURCE 135: American Dental Association
CJ Current Procedural Terminology (CPT) Codes
CODE SOURCE 133: Current Procedural Terminology (CPT) Codes
HC Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
CODE SOURCE 130: Healthcare Common Procedure Coding
System
ID International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) -
Procedure
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
IV Home Infusion EDI Coalition (HIEC) Product/Service
Code
CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List
N4 National Drug Code in 5-4-2 Format
CODE SOURCE 240: National Drug Code by Format
ZZ Mutually Defined
300393 Use this code only for International Classification of
Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS).

CODE SOURCE 896: International Classification of

Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS)
REQUIRED EQ02 - 2 234 Product/Service ID M AN 1/48
Identifying number for a product or service
SEMANTIC:
If C003-08 is used, then C003-02 represents the beginning value in the
range in which the code occurs.

OD: 270B1_2110D_EQ02_C00302_ProcedureCode

IMPLEMENTATION NAME: Procedure Code

300117 Use this number for the product/service ID as identified by

the preceding data element (EQ02-1).

188 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110D • EQ
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

SITUATIONAL EQ02 - 3 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-03 modifies the value in C003-02 and C003-08.

300365 SITUATIONAL RULE: Requiredwhen a modifier clarifies/improves

the accuracy of the associated procedure code, the modifier
is available and when the information receiver believes that
the information source supports this high level of
functionality. If not required by this implementation guide,
do not send.

OD: 270B1_2110D_EQ02_C00303_ProcedureModifier

300230 Used when an information source supports or may be

thought to support this high level of functionality if
modifiers are required to further specify the service. If not
supported, information source will process without this
data element.

SITUATIONAL EQ02 - 4 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-04 modifies the value in C003-02 and C003-08.

300366 SITUATIONAL RULE: Requiredwhen a second modifier

clarifies/improves the accuracy of the associated procedure
code, the modifier is available and when the information
receiver believes that the information source supports this
high level of functionality. If not required by this
implementation guide, do not send.

OD: 270B1_2110D_EQ02_C00304_ProcedureModifier

300230 Used when an information source supports or may be

thought to support this high level of functionality if
modifiers are required to further specify the service. If not
supported, information source will process without this
data element.

APRIL 2008 189

005010X279 • 270 • 2110D • EQ ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY TECHNICAL REPORT • TYPE 3

SITUATIONAL EQ02 - 5 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-05 modifies the value in C003-02 and C003-08.

300367 SITUATIONAL RULE: Requiredwhen a third modifier

clarifies/improves the accuracy of the associated procedure
code, the modifier is available and when the information
receiver believes that the information source supports this
high level of functionality. If not required by this
implementation guide, do not send.

OD: 270B1_2110D_EQ02_C00305_ProcedureModifier

300230 Used when an information source supports or may be

thought to support this high level of functionality if
modifiers are required to further specify the service. If not
supported, information source will process without this
data element.

SITUATIONAL EQ02 - 6 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-06 modifies the value in C003-02 and C003-08.

300368 SITUATIONAL RULE: Requiredwhen a fourth modifier

clarifies/improves the accuracy of the associated procedure
code, the modifier is available and when the information
receiver believes that the information source supports this
high level of functionality. If not required by this
implementation guide, do not send.

OD: 270B1_2110D_EQ02_C00306_ProcedureModifier

300230 Used when an information source supports or may be

thought to support this high level of functionality if
modifiers are required to further specify the service. If not
supported, information source will process without this
data element.

NOT USED EQ02 - 7 352 Description O AN 1/80

NOT USED EQ02 - 8 234 Product/Service ID O AN 1/48
NOT USED EQ03 1207 Coverage Level Code O1 ID 3/3
NOT USED EQ04 1336 Insurance Type Code O1 ID 1/3
SITUATIONAL EQ05 C004 COMPOSITE DIAGNOSIS CODE POINTER O1
To identify one or more diagnosis code pointers

300338 SITUATIONAL RULE: Required

when a 2100D HI segment is used. If not
required by this implementation guide, do not send.

OD: 270B1_2110D_EQ05_C004

190 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110D • EQ
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

REQUIRED EQ05 - 1 1328 Diagnosis Code Pointer M N0 1/2

A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-01 identifies the primary diagnosis code for this service line.

OD: 270B1_2110D_EQ05_C00401_DiagnosisCodePointer

300339 This first pointer designates the primary diagnosis for this
EQ segment. Remaining diagnosis pointers indicate
declining level of importance to the EQ segment.
Acceptable values are 1 through 8, and correspond to
Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100D.
SITUATIONAL EQ05 - 2 1328 Diagnosis Code Pointer O N0 1/2
A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-02 identifies the second diagnosis code for this service line.

300329 SITUATIONAL RULE: Required when it is necessary to designate a

second diagnosis related to this EQ segment. If not
required by this implementation guide, do not send.

OD: 270B1_2110D_EQ05_C00402_DiagnosisCodePointer

300340 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100D.
SITUATIONAL EQ05 - 3 1328 Diagnosis Code Pointer O N0 1/2
A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-03 identifies the third diagnosis code for this service line.

300331 SITUATIONAL RULE: Required

when it is necessary to designate a
third diagnosis related to this EQ segment. If not required
by this implementation guide, do not send.

OD: 270B1_2110D_EQ05_C00403_DiagnosisCodePointer

300340 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100D.
SITUATIONAL EQ05 - 4 1328 Diagnosis Code Pointer O N0 1/2
A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-04 identifies the fourth diagnosis code for this service line.

300332 SITUATIONAL RULE: Required

when it is necessary to designate a
fourth diagnosis related to this EQ segment. If not required
by this implementation guide, do not send.

OD: 270B1_2110D_EQ05_C00404_DiagnosisCodePointer

300340 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100D.

APRIL 2008 191

 005010X279 • 270 • 2110D • III ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INQUIRY INFORMATION TECHNICAL REPORT • TYPE 3
INFORMATION DEPENDENT• ELIGIBILITY
005010X279 270 • 2110DOR
• IIIBENEFIT ADDITIONAL INQUIRY INFORMATION
III

SEGMENT DETAIL
194
300
III - DEPENDENT ELIGIBILITY OR BENEFIT
ADDITIONAL INQUIRY INFORMATION
X12 Segment Name: Information
X12 Purpose: To report information
X12 Syntax: 1. P0102
If either III01 or III02 is present, then the other is required.
2. L030405
If III03 is present, then at least one of III04 or III05 are required.
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

Segment Repeat: 1

Usage: SITUATIONAL

74
03
30 Situational Rule: Required when the information receiver believes the Facility Type
information is relevant to the inquiry and the information is available. If
not required by this implementation guide, do not send.

231
300 TR3 Notes: 1. Use the III segment when an information source supports or may be
thought to support this level of functionality. If not supported, the
information source will process without this segment.

394
300 TR3 Example: III✽ZZ✽21~

DIAGRAM

III01 1270 III02 1271 III03 1136 III04 933 III05 380 III06 C001
Code List Industry Code
✽ Free-Form ✽ Quantity Composite
III ✽ Qual Code
✽
Code
✽
Category Message Txt
✽
Unit of Mea
X1 ID 1/3 X1 AN 1/30 O1 ID 2/2 X1 AN 1/264 X1 R 1/15 O1

III07 752 III08 752 III09 752

Layer/Posit Layer/Posit Layer/Posit
✽ ✽ ✽ ~
Code Code Code
O1 ID 2/2 O1 ID 2/2 O1 ID 2/2

192 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110D • III
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INQUIRY INFORMATION

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED III01 1270 Code List Qualifier Code X1 ID 1/3

Code identifying a specific industry code list
SYNTAX: P0102

OD: 270B1_2110D_III01__CodeListQualifierCode

300185 Use this code to specify the code that is following in the III02 is a
Facility Type Code.
CODE DEFINITION

ZZ Mutually Defined
300215 Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of
Service Codes for Professional Claims.

APRIL 2008 193

005010X279 • 270 • 2110D • III ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INQUIRY INFORMATION TECHNICAL REPORT • TYPE 3

REQUIRED III02 1271 Industry Code X1 AN 1/30

Code indicating a code from a specific industry code list
SYNTAX: P0102

OD: 270B1_2110D_III02__IndustryCode

300186 Use this element for codes identifying a place of service from code
source 237. As a courtesy, the codes are listed below; however, the
code list is thought to be complete at the time of publication of this
implementation guideline. Since this list is subject to change, only
codes contained in the document available from code source 237
are to be supported in this transaction and take precedence over
any and all codes listed here.
01 Pharmacy
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-based Facility
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service
NOT USED III03 1136 Code Category O1 ID 2/2

194 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110D • III
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INQUIRY INFORMATION

NOT USED III04 933 Free-form Message Text X1 AN 1/264

NOT USED III05 380 Quantity X1 R 1/15
NOT USED III06 C001 COMPOSITE UNIT OF MEASURE O1
NOT USED III07 752 Surface/Layer/Position Code O1 ID 2/2
NOT USED III08 752 Surface/Layer/Position Code O1 ID 2/2
NOT USED III09 752 Surface/Layer/Position Code O1 ID 2/2

APRIL 2008 195

 005010X279 • 270 • 2110D • REF ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ADDITIONAL INFORMATION TECHNICAL REPORT • TYPE 3
REFERENCE INFORMATION DEPENDENT• ADDITIONAL
005010X279 270 • 2110D •INFORMATION
REF
REF

SEGMENT DETAIL
107
300
REF - DEPENDENT ADDITIONAL
INFORMATION
X12 Segment Name: Reference Information
X12 Purpose: To specify identifying information
X12 Syntax: 1. R0203
At least one of REF02 or REF03 is required.
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

Segment Repeat: 1

Usage: SITUATIONAL

21
01
30 Situational Rule: Required when the dependent has received a referral or prior
authorization number and the information receiver believes the
information is relevant to the inquiry (such as for a benefit or procedure
that requires a referral or prior authorization) and the information is
available. If not required by this implementation guide do not send.

161
300 TR3 Notes: 1. Use this segment when it is necessary to provide a referral or prior
authorization number for the benefit being inquired about.

062
300 TR3 Example: REF✽9F✽660415~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

Reference Reference
✽ Description ✽ Reference
REF ✽
Ident Qual
✽
Ident Identifier ~
M1 ID 2/3 X1 AN 1/50 X1 AN 1/80 O1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED REF01 128 Reference Identification Qualifier M1 ID 2/3

Code qualifying the Reference Identification

OD: 270B1_2110D_REF01__ReferenceIdentificationQualifier

300039 Use this code to specify or qualify the type of reference number
that is following in REF02.
CODE DEFINITION

9F Referral Number
G1 Prior Authorization Number

196 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110D • REF
TECHNICAL REPORT • TYPE 3 DEPENDENT ADDITIONAL INFORMATION

REQUIRED REF02 127 Reference Identification X1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: R0203

OD: 270B1_2110D_REF02__PriorAuthorizationorReferralNumber

IMPLEMENTATION NAME: Prior Authorization or Referral Number

300038 Use this reference number as qualified by the preceding data

element (REF01).
NOT USED REF03 352 Description X1 AN 1/80
NOT USED REF04 C040 REFERENCE IDENTIFIER O1

APRIL 2008 197

 005010X279 • 270 • 2110D • DTP ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY/BENEFIT DATE TECHNICAL REPORT • TYPE 3
DATE OR TIME OR PERIOD DEPENDENT• ELIGIBILITY/BENEFIT
005010X279 270 • 2110D • DTP DATE
DTP

SEGMENT DETAIL
129
300
DTP - DEPENDENT ELIGIBILITY/BENEFIT
DATE
X12 Segment Name: Date or Time or Period
X12 Purpose: To specify any or all of a date, a time, or a time period
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

Segment Repeat: 1

Usage: SITUATIONAL

86
03
30 Situational Rule: Required when the plan date(s) are different from the date(s) provided in
the 2100C loop. If not required by this implementation guide, do not send.

118
300 TR3 Notes: 1. Use this segment to convey plan dates associated with the
information contained in the corresponding EQ segment.

195
300 2. This segment is only to be used to override dates provided in Loop
2100D when the date differs from the date provided in the DTP
segment in Loop 2100D. Dates that apply to the entire request must be
placed in the DTP segment in Loop 2100D. In order for a date to
appear here, there must be a date or a date range in the
corresponding 2100D loop.

245
300 TR3 Example: DTP✽291✽D8✽20051031~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251

Date/Time Date Time Date Time
DTP ✽
Qualifier
✽
Format Qual
✽
Period ~
M1 ID 3/3 M1 ID 2/3 M1 AN 1/35

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED DTP01 374 Date/Time Qualifier M1 ID 3/3

Code specifying type of date or time, or both date and time

OD: 270B1_2110D_DTP01__DateTimeQualifier

IMPLEMENTATION NAME: Date Time Qualifier

CODE DEFINITION

291 Plan

198 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270 • 2110D • DTP
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY/BENEFIT DATE

REQUIRED DTP02 1250 Date Time Period Format Qualifier M1 ID 2/3

Code indicating the date format, time format, or date and time format
SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

OD: 270B1_2110D_DTP02__DateTimePeriodFormatQualifier

300043 Use this code to specify the format of the date(s) or time(s) that
follow in the next data element.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

RD8 Range of Dates Expressed in Format CCYYMMDD-
CCYYMMDD
REQUIRED DTP03 1251 Date Time Period M 1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times

OD: 270B1_2110D_DTP03__DateTimePeriod

300042 Use this date for the date(s) as qualified by the preceding data
elements.

APRIL 2008 199

 005010X279 • 270 • SE ASC X12N • INSURANCE SUBCOMMITTEE
TRANSACTION SET TRAILER TECHNICAL REPORT • TYPE 3
TRANSACTION SET TRAILER TRANSACTION
005010X279 • 270
SET• SE
TRAILER
SE

SEGMENT DETAIL
130
300
SE - TRANSACTION SET TRAILER
X12 Segment Name: Transaction Set Trailer
X12 Purpose: To indicate the end of the transaction set and provide the count of the
transmitted segments (including the beginning (ST) and ending (SE) segments)
X12 Comments: 1. SE is the last segment of each transaction set.
Segment Repeat: 1

Usage: REQUIRED

063
300 TR3 Notes: 1. Use this segment to mark the end of a transaction set and provide
control information on the total number of segments included in the
transaction set.

064
300 TR3 Example: SE✽41✽0001~

DIAGRAM

SE01 96 SE02 329

Number of TS Control
SE ✽ Inc Segs
✽
Number ~
M1 N0 1/10 M1 AN 4/9

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED SE01 96 Number of Included Segments M1 N0 1/10

Total number of segments included in a transaction set including ST and SE
segments

OD: 270B1__SE01__TransactionSegmentCount

IMPLEMENTATION NAME: Transaction Segment Count

300065 Use this number to indicate the total number of segments included
in the transaction set inclusive of the ST and SE segments.

REQUIRED SE02 329 Transaction Set Control Number M 1 AN 4/9

Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set

OD: 270B1__SE02__TransactionSetControlNumber

300122 The transaction set control numbers in ST02 and SE02 must be
identical. This unique number also aids in error resolution
research. Start with a number, for example “0001", and increment
from there. This number must be unique within a specific functional
group (segments GS through GE) and interchange, but can repeat
in other groups and interchanges.

200 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE
TECHNICAL REPORT • TYPE 3 005010X279 • 271

2.5 Transaction Set Listing

2.5.1 Implementation
This section lists the levels, loops, and segments contained in this implementa-
tion. It also serves as an index to the segment detail. Refer to section 2.1 Presen-
tation Examples for detailed information on the components of the
Implementation section.

APRIL 2008 201

 ASC X12N • INSURANCE SUBCOMMITTEE
005010X279 • 271 TECHNICAL REPORT • TYPE 3
005010X279 • 271

MARCH 28, 2008

IMPLEMENTATION

271 Health Care Eligibility Benefit Response

Table 1 - Header
PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

209 0100 ST Transaction Set Header R 1

211 0200 BHT Beginning of Hierarchical Transaction R 1

Table 2 - Information Source Detail

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

LOOP ID - 2000A INFORMATION SOURCE LEVEL >1

213 0100 HL Information Source Level R 1
215 0250 AAA Request Validation S 9
LOOP ID - 2100A INFORMATION SOURCE NAME 1
218 0300 NM1 Information Source Name R 1
221 0800 PER Information Source Contact Information S 3
226 0850 AAA Request Validation S 9

Table 2 - Information Receiver Detail

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

LOOP ID - 2000B INFORMATION RECEIVER LEVEL >1

229 0100 HL Information Receiver Level S 1
LOOP ID - 2100B INFORMATION RECEIVER NAME 1
232 0300 NM1 Information Receiver Name R 1
236 0400 REF Information Receiver Additional Identification S 9
238 0850 AAA Information Receiver Request Validation S 9
241 0900 PRV Information Receiver Provider Information S 1

Table 2 - Subscriber Detail

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

LOOP ID - 2000C SUBSCRIBER LEVEL >1

243 0100 HL Subscriber Level S 1
246 0200 TRN Subscriber Trace Number S 3
LOOP ID - 2100C SUBSCRIBER NAME 1
249 0300 NM1 Subscriber Name R 1
253 0400 REF Subscriber Additional Identification S 9
257 0600 N3 Subscriber Address S 1
259 0700 N4 Subscriber City, State, ZIP Code S 1
262 0850 AAA Subscriber Request Validation S 9
265 0900 PRV Provider Information S 1

202 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE
TECHNICAL REPORT • TYPE 3 005010X279 • 271

268 1000 DMG Subscriber Demographic Information S 1

271 1100 INS Subscriber Relationship S 1
274 1150 HI Subscriber Health Care Diagnosis Code S 1
283 1200 DTP Subscriber Date S 9
285 1275 MPI Subscriber Military Personnel Information S 1
LOOP ID - 2110C SUBSCRIBER ELIGIBILITY OR >1
BENEFIT INFORMATION
289 1300 EB Subscriber Eligibility or Benefit Information S 1
309 1350 HSD Health Care Services Delivery S 9
314 1400 REF Subscriber Additional Identification S 9
317 1500 DTP Subscriber Eligibility/Benefit Date S 20
319 1600 AAA Subscriber Request Validation S 9
322 2500 MSG Message Text S 10
LOOP ID - 2115C SUBSCRIBER ELIGIBILITY OR 10
BENEFIT ADDITIONAL INFORMATION
324 2600 III Subscriber Eligibility or Benefit Additional Information S 1
328 3300 LS Loop Header S 1
LOOP ID - 2120C SUBSCRIBER BENEFIT RELATED 23
ENTITY NAME
329 3400 NM1 Subscriber Benefit Related Entity Name S 1
335 3600 N3 Subscriber Benefit Related Entity Address S 1
336 3700 N4 Subscriber Benefit Related Entity City, State, ZIP Code S 1
339 3800 PER Subscriber Benefit Related Entity Contact Information S 3
344 3900 PRV Subscriber Benefit Related Provider Information S 1
346 4000 LE Loop Trailer S 1

Table 2 - Dependent Detail

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

LOOP ID - 2000D DEPENDENT LEVEL >1

347 0100 HL Dependent Level S 1
351 0200 TRN Dependent Trace Number S 3
LOOP ID - 2100D DEPENDENT NAME 1
354 0300 NM1 Dependent Name R 1
357 0400 REF Dependent Additional Identification S 9
361 0600 N3 Dependent Address S 1
363 0700 N4 Dependent City, State, ZIP Code S 1
366 0850 AAA Dependent Request Validation S 9
369 0900 PRV Provider Information S 1
372 1000 DMG Dependent Demographic Information S 1
375 1100 INS Dependent Relationship S 1
378 1150 HI Dependent Health Care Diagnosis Code S 1
387 1200 DTP Dependent Date S 9
389 1275 MPI Dependent Military Personnel Information S 1
LOOP ID - 2110D DEPENDENT ELIGIBILITY OR >1
BENEFIT INFORMATION
393 1300 EB Dependent Eligibility or Benefit Information S 1
412 1350 HSD Health Care Services Delivery S 9
417 1400 REF Dependent Additional Identification S 9
420 1500 DTP Dependent Eligibility/Benefit Date S 20
422 1600 AAA Dependent Request Validation S 9

APRIL 2008 203

 ASC X12N • INSURANCE SUBCOMMITTEE
005010X279 • 271 TECHNICAL REPORT • TYPE 3

425 2500 MSG Message Text S 10

LOOP ID - 2115D DEPENDENT ELIGIBILITY OR 10
BENEFIT ADDITIONAL INFORMATION
427 2600 III Dependent Eligibility or Benefit Additional Information S 1
431 3300 LS Loop Header S 1
LOOP ID - 2120D DEPENDENT BENEFIT RELATED 23
ENTITY NAME
432 3400 NM1 Dependent Benefit Related Entity Name S 1
438 3600 N3 Dependent Benefit Related Entity Address S 1
439 3700 N4 Dependent Benefit Related Entity City, State, ZIP Code S 1
442 3800 PER Dependent Benefit Related Entity Contact Information S 3
447 3900 PRV Dependent Benefit Related Provider Information S 1
449 4000 LE Loop Trailer S 1
450 4100 SE Transaction Set Trailer R 1

204 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE
TECHNICAL REPORT • TYPE 3 005010X279 • 271

2.5.2 X12 Standard

This section is included as a reference. The implementation guide reference clari-
fies actual usage. Refer to section 2.1 Presentation Examples for detailed infor-
mation on the components of the X12 Standard section.

APRIL 2008 205

 ASC X12N • INSURANCE SUBCOMMITTEE
005010X279 • 271 TECHNICAL REPORT • TYPE 3

STANDARD

271 Eligibility, Coverage or Benefit Information

Functional Group ID: HB
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.

Table 1 - Header

PAGE # POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

0100 ST Transaction Set Header M 1

0200 BHT Beginning of Hierarchical Transaction M 1

Table 2 - Detail

PAGE # POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

LOOP ID - 2000 >1

0100 HL Hierarchical Level M 1
0200 TRN Trace O 9
0250 AAA Request Validation O 9
LOOP ID - 2100 >1
0300 NM1 Individual or Organizational Name O 1
0400 REF Reference Information O 9
0500 N2 Additional Name Information O 1
0600 N3 Party Location O 1
0700 N4 Geographic Location O 1
0800 PER Administrative Communications Contact O 3
0850 AAA Request Validation O 9
0900 PRV Provider Information O 1
1000 DMG Demographic Information O 1
1100 INS Insured Benefit O 1
1150 HI Health Care Information Codes O 1
1200 DTP Date or Time or Period O 9
1250 LUI Language Use O 9
1275 MPI Military Personnel Information O 9
LOOP ID - 2110 >1
1300 EB Eligibility or Benefit Information O 1
1350 HSD Health Care Services Delivery O 9
1400 REF Reference Information O 9
1500 DTP Date or Time or Period O 20
1600 AAA Request Validation O 9
1700 VEH Vehicle Information O 1
1800 PID Product/Item Description O 1
1900 PDR Property Description - Real O 1

206 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE
TECHNICAL REPORT • TYPE 3 005010X279 • 271

2000 PDP Property Description - Personal O 1

2100 LIN Item Identification O 1
2200 EM Equipment Characteristics O 1
2300 SD1 Safety Data O 1
2400 PKD Packaging Description O 1
2500 MSG Message Text O 10
LOOP ID - 2115 >1
2600 III Information O 1
2700 DTP Date or Time or Period O 5
2800 AMT Monetary Amount Information O 5
2900 PCT Percent Amounts O 5
LOOP ID - 2117 >1
3000 LQ Industry Code Identification O 1
3100 AMT Monetary Amount Information O 5
3200 PCT Percent Amounts O 5
3300 LS Loop Header O 1
LOOP ID - 2120 >1
3400 NM1 Individual or Organizational Name O 1
3500 N2 Additional Name Information O 1
3600 N3 Party Location O 1
3700 N4 Geographic Location O 1
3800 PER Administrative Communications Contact O 3
3900 PRV Provider Information O 1
4000 LE Loop Trailer O 1
4100 SE Transaction Set Trailer M 1
NOTE:
2/0200 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.

APRIL 2008 207

 ASC X12N • INSURANCE SUBCOMMITTEE
005010X279 • 271 TECHNICAL REPORT • TYPE 3

2.6 271 - Segment Detail

This section specifies the segments, data elements, and codes for this implemen-
tation. Refer to section 2.1 Presentation Examples for detailed information on the
components of the Segment Detail section.

208 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • ST
TECHNICAL REPORT • TYPE 3 TRANSACTION SET HEADER
TRANSACTION SET HEADER TRANSACTION
005010X279 • 271
SET• ST
HEADER
ST

SEGMENT DETAIL
587
300
ST - TRANSACTION SET HEADER
X12 Segment Name: Transaction Set Header
X12 Purpose: To indicate the start of a transaction set and to assign a control number
Segment Repeat: 1

Usage: REQUIRED

443
300 TR3 Notes: 1. Use this control segment to mark the start of a transaction set. One
ST segment exists for every transaction set that occurs within a
functional group.

477
300 TR3 Example: ST✽271✽0001✽005010X279~

DIAGRAM

ST01 143 ST02 329 ST03 1705

TS ID TS Control Imple Conv
ST ✽
Code
✽
Number
✽
Reference
~
M1 ID 3/3 M1 AN 4/9 O1 AN 1/35

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED ST01 143 Transaction Set Identifier Code M1 ID 3/3

Code uniquely identifying a Transaction Set
SEMANTIC: The transaction set identifier (ST01) is used by the translation routines
of the interchange partners to select the appropriate transaction set definition
(e.g., 810 selects the Invoice Transaction Set).

OD: 271B1__ST01__TransactionSetIdentifierCode

300445 Use this code to identify the transaction set ID for the transaction
set that will follow the ST segment. Each X12 standard has a
transaction set identifier code that is unique to that transaction set.
CODE DEFINITION

271 Eligibility, Coverage or Benefit Information

REQUIRED ST02 329 Transaction Set Control Number M 1 AN 4/9
Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set

OD: 271B1__ST02__TransactionSetControlNumber

300559 The transaction set control numbers in ST02 and SE02 must be
identical. This unique number also aids in error resolution
research. Start with a number, for example “0001", and increment
from there.

APRIL 2008 209

005010X279 • 271 • ST ASC X12N • INSURANCE SUBCOMMITTEE
TRANSACTION SET HEADER TECHNICAL REPORT • TYPE 3

REQUIRED ST03 1705 Implementation Convention Reference O 1 AN 1/35

Reference assigned to identify Implementation Convention
SEMANTIC: The implementation convention reference (ST03) is used by the
translation routines of the interchange partners to select the appropriate
implementation convention to match the transaction set definition. When used,
this implementation convention reference takes precedence over the
implementation reference specified in the GS08.

OD: 271B1__ST03__ImplementationConventionReference

300927 This element must be populated with 005010X279.

300928 This element contains the same value as GS08. Some translator
products strip off the ISA and GS segments prior to application
(ST/SE) processing. Providing the information from the GS08 at this
level will ensure that the appropriate application mapping is utilized
at translation time.

210 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • BHT
TECHNICAL REPORT • TYPE 3 BEGINNING OF HIERARCHICAL TRANSACTION
BEGINNING OF HIERARCHICAL TRANSACTION 005010X279 • 271
BEGINNING OF • BHT
HIERARCHICAL TRANSACTION
BHT

SEGMENT DETAIL
588
300
BHT - BEGINNING OF HIERARCHICAL
TRANSACTION
X12 Segment Name: Beginning of Hierarchical Transaction
X12 Purpose: 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
Segment Repeat: 1

Usage: REQUIRED

500
300 TR3 Notes: 1. Use this required segment to start the transaction set and indicate the
sequence of the hierarchical levels of information that will follow in
Table 2.

657
300 TR3 Example: BHT✽0022✽11✽199800114000001✽19980101✽1401~

DIAGRAM

BHT01 1005 BHT02 353 BHT03 127 BHT04 373 BHT05 337 BHT06 640
Hierarch TS Purpose Reference Date Time Transaction
BHT ✽ Struct Code
✽
Code
✽
Ident
✽ ✽ ✽
Type Code ~
M1 ID 4/4 M1 ID 2/2 O1 AN 1/50 O1 DT 8/8 O1 TM 4/8 O1 ID 2/2

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED BHT01 1005 Hierarchical Structure Code M1 ID 4/4

Code indicating the hierarchical application structure of a transaction set that
utilizes the HL segment to define the structure of the transaction set

OD: 271B1__BHT01__HierarchicalStructureCode

300560 Use this code to specify the sequence of hierarchical levels that
may appear in the transaction set. This code only indicates the
sequence of the levels, not the requirement that all levels be
present. For example, if code “0022" is used, the dependent level
may or may not be present for each subscriber.
CODE DEFINITION

0022 Information Source, Information Receiver,

Subscriber, Dependent
REQUIRED BHT02 353 Transaction Set Purpose Code M1 ID 2/2
Code identifying purpose of transaction set

OD: 271B1__BHT02__TransactionSetPurposeCode

CODE DEFINITION

06 Confirmation
300859 Use this code only to acknowledge the successful
cancellation of a 270 transaction that was received
with a BHT02 value of “01" Cancellation.

APRIL 2008 211

005010X279 • 271 • BHT ASC X12N • INSURANCE SUBCOMMITTEE
BEGINNING OF HIERARCHICAL TRANSACTION TECHNICAL REPORT • TYPE 3

11 Response
SITUATIONAL BHT03 127 Reference Identification O 1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SEMANTIC: BHT03 is the number assigned by the originator to identify the
transaction within the originator’s business application system.

300929 SITUATIONAL RULE: Requiredwhen the transaction is used in Real Time

(See Section 1.4.3). If not required by this implementation guide,
may be provided at sender’s discretion but cannot be required by
the receiver.

OD: 271B1__BHT03__SubmitterTransactionIdentifier

IMPLEMENTATION NAME: Submitter Transaction Identifier

300850 This information may be sent at the creator of the 271’s discretion if
using the transaction in a Batch mode and a Submitter Transaction
Identifier was received in the 270 transaction BHT03, otherwise this
is not used. Due to the nature of batch transaction processing, the
receiver of the 270 transaction (whether it is a clearinghouse or
information source) may or may not be able to return the 270
BHT03 value in the 271 BHT03. See Section 1.4.6 Information
Linkage for additional information and requirements.

300851 This element is to be used to trace the transaction from one point
to the next point, such as when the transaction is passed from one
clearinghouse to another clearinghouse. This identifier is to be the
identifier received in the BHT03 of the corresponding 270
transaction. This identifier is not to be passed through the
complete life of the transaction, rather replaced with the identifier
received in the 270.

REQUIRED BHT04 373 Date O1 DT 8/8

Date expressed as CCYYMMDD where CC represents the first two digits of the
calendar year
SEMANTIC: BHT04 is the date the transaction was created within the business
application system.

OD: 271B1__BHT04__TransactionSetCreationDate

IMPLEMENTATION NAME: Transaction Set Creation Date

300501 Use this date for the date the transaction set was generated.
REQUIRED BHT05 337 Time O 1 TM 4/8
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S =
integer seconds (00-59) and DD = decimal seconds; decimal seconds are
expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC: BHT05 is the time the transaction was created within the business
application system.

OD: 271B1__BHT05__TransactionSetCreationTime

IMPLEMENTATION NAME: Transaction Set Creation Time

300502 Use this time for the time the transaction set was generated.

NOT USED BHT06 640 Transaction Type Code O1 ID 2/2

212 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000A • HL
TECHNICAL REPORT • TYPE 3 INFORMATION SOURCE LEVEL
HIERARCHICAL LEVEL 005010X279
INFORMATION• 271 • 2000A
SOURCE • HL
LEVEL
HL

SEGMENT DETAIL
524
300
HL - INFORMATION SOURCE LEVEL
X12 Segment Name: Hierarchical Level
X12 Purpose: To identify dependencies among and the content of hierarchically related
groups of data segments
X12 Comments: 1. The HL segment is used to identify levels of detail information using a
hierarchical structure, such as relating line-item data to shipment data, and
packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
Loop: 2000A — INFORMATION SOURCE LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: REQUIRED

436
300 TR3 Notes: 1. Use this segment to identify the hierarchical or entity level of
information being conveyed. The HL structure allows for the efficient
nesting of related occurrences of information. The developers’ intent
is to clearly identify the relationship of the patient to the subscriber
and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient)

can be grouped together under the same provider or the information
for multiple providers or information receivers can be grouped
together for the same payer or information source. See Section 1.3.2
for limitations on the number of occurrences of patients.

505
300 2. An example of the overall structure of the transaction set when used
in batch mode is:

Information Source Loop 2000A

Information Receiver Loop 2000B
Subscriber Loop 2000C
Dependent Loop 2000D
Eligibility or Benefit Information
Subscriber Loop 2000C
Eligibility or Benefit Information
Dependent Loop 2000D
Eligibility or Benefit Information

478
300 TR3 Example: HL✽1✽✽20✽1~

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736

Hierarch Hierarch Hierarch Hierarch
HL ✽ ID Number
✽
Parent ID
✽
Level Code
✽
Child Code ~
M1 AN 1/12 O1 AN 1/12 M1 ID 1/2 O1 ID 1/1

APRIL 2008 213

005010X279 • 271 • 2000A • HL ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION SOURCE LEVEL TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HL01 628 Hierarchical ID Number M 1 AN 1/12

A unique number assigned by the sender to identify a particular data segment in
a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence
of the HL segment in the transaction set. For example, HL01 could be used to
indicate the number of occurrences of the HL segment, in which case the value of
HL01 would be “1" for the initial HL segment and would be incremented by one in
each subsequent HL segment within the transaction.

OD: 271B1_2000A_HL01__HierarchicalIDNumber

300447 Use the sequentially assigned positive number to identify each

specific occurrence of an HL segment within a transaction set. The
first HL segment in the transaction should begin with the number
one and be incremented by one for each successive occurrence of
the HL segment within that specific transaction set (ST through SE).

300709 An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
NOT USED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12
REQUIRED HL03 735 Hierarchical Level Code M1 ID 1/2
Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the
current HL segment up to the next occurrence of an HL segment in the
transaction. For example, HL03 is used to indicate that subsequent segments in
the HL loop form a logical grouping of data referring to shipment, order, or item-
level information.

OD: 271B1_2000A_HL03__HierarchicalLevelCode

300885 All data that follows this HL segment is associated with the
Information Source identified by the level code. This association
continues until the next occurrence of an HL segment.
CODE DEFINITION

20 Information Source
REQUIRED HL04 736 Hierarchical Child Code O1 ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL
segments related to the current HL segment.

OD: 271B1_2000A_HL04__HierarchicalChildCode

300886 Use this code to indicate whether there are additional hierarchical
levels subordinate to this Information Source.
CODE DEFINITION

0 No Subordinate HL Segment in This Hierarchical

Structure.
1 Additional Subordinate HL Data Segment in This
Hierarchical Structure.

214 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000A • AAA
TECHNICAL REPORT • TYPE 3 REQUEST VALIDATION
REQUEST VALIDATION 005010X279 • 271 • 2000A • AAA
REQUEST VALIDATION
AAA

SEGMENT DETAIL
589
300
AAA - REQUEST VALIDATION
X12 Segment Name: Request Validation
X12 Purpose: To specify the validity of the request and indicate follow-up action authorized
Loop: 2000A — INFORMATION SOURCE LEVEL

Segment Repeat: 9

Usage: SITUATIONAL

30
09 Situational Rule: Required when the request could not be processed at a system or
application level based on the entities identified in ISA06, ISA08, GS02 or
GS03 and to indicate what action the originator of the request transaction
should take. If not required by this implementation guide, do not send.

710
300 TR3 Notes: 1. Use of this segment at this location in the HL is to identify reasons
why a request cannot be processed based on the entities identified in
ISA06, ISA08, GS02 or GS03.

479
300 TR3 Example: AAA✽Y✽✽42✽Y~

DIAGRAM

AAA01 1073 AAA02 559 AAA03 901 AAA04 889

✽ Yes/No Cond ✽ Agency Reject Follow-up

AAA Resp Code Qual Code
✽
Reason Code
✽
Act Code
~
M1 ID 1/1 O1 ID 2/2 O1 ID 2/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED AAA01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: AAA01 designates whether the request is valid or invalid. Code “Y”
indicates that the code is valid; code “N” indicates that the code is invalid.

OD: 271B1_2000A_AAA01__ValidRequestIndicator

IMPLEMENTATION NAME: Valid Request Indicator

CODE DEFINITION

N No
300561 Use this code to indicate that the request or an
element in the request is not valid. The transaction
has been rejected as identified by the code in
AAA03.
Y Yes
300562 Use this code to indicate that the request is valid,
however the transaction has been rejected as
identified by the code in AAA03.
NOT USED AAA02 559 Agency Qualifier Code O1 ID 2/2

APRIL 2008 215

005010X279 • 271 • 2000A • AAA ASC X12N • INSURANCE SUBCOMMITTEE
REQUEST VALIDATION TECHNICAL REPORT • TYPE 3

REQUIRED AAA03 901 Reject Reason Code O1 ID 2/2

Code assigned by issuer to identify reason for rejection

OD: 271B1_2000A_AAA03__RejectReasonCode

300711 Use this code to indicate the reason why the transaction was
unable to be processed successfully by the entity identified in
either ISA08 or GS03.
CODE DEFINITION

04 Authorized Quantity Exceeded

300770 Use this code to indicate that the transaction
exceeds the number of patient requests allowed by
the entity identified in either ISA08 or GS03. See
section 1.4.3 Batch and Real Time for more
information regarding the number of patient
requests allowed in a transaction. This is not to be
used to indicate that the number of patient requests
exceeds the number allowed by the Information
Source identified in Loop 2100A.
41 Authorization/Access Restrictions
300712 Use this code to indicate that the entity identified in
GS02 is not authorized to submit 270 transactions to
the entity identified in either ISA08 or GS03. This is
not to be used to indicate Authorization/Access
Restrictions as related to the Information Source
Identified in Loop 2100A.
42 Unable to Respond at Current Time
300713 Use this code to indicate that the entity identified in
either ISA08 or GS03 is unable to process the
transaction at the current time. This indicates that
there is a problem within the systems of the entity
identified in either ISA08 or GS03 and is not related
to any problem with the Information Source
Identified in Loop 2100A.
79 Invalid Participant Identification
300714 Use this code to indicate that the value in either
GS02 or GS03 is invalid.
REQUIRED AAA04 889 Follow-up Action Code O1 ID 1/1
Code identifying follow-up actions allowed

OD: 271B1_2000A_AAA04__FollowupActionCode

300437 Use this code to instruct the recipient of the 271 about what action
needs to be taken, if any, based on the validity code and the reject
reason code (if applicable).
CODE DEFINITION

C Please Correct and Resubmit

N Resubmission Not Allowed
P Please Resubmit Original Transaction
R Resubmission Allowed
S Do Not Resubmit; Inquiry Initiated to a Third Party

216 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000A • AAA
TECHNICAL REPORT • TYPE 3 REQUEST VALIDATION

Y Do Not Resubmit; We Will Hold Your Request and

Respond Again Shortly

APRIL 2008 217

 005010X279 • 271 • 2100A • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION SOURCE NAME TECHNICAL REPORT • TYPE 3
INDIVIDUAL OR ORGANIZATIONAL NAME 005010X279
INFORMATION• 271 • 2100A
SOURCE • NM1
NAME
NM1

SEGMENT DETAIL
525
300
NM1 - INFORMATION SOURCE NAME
X12 Segment Name: Individual or Organizational Name
X12 Purpose: To supply the full name of an individual or organizational entity
X12 Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
3. C1203
If NM112 is present, then NM103 is required.
Loop: 2100A — INFORMATION SOURCE NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

439
300 TR3 Notes: 1. Use this segment to identify an entity by name and identification
number. This NM1 loop is used to identify the eligibility or benefit
information source (e.g., insurance company, HMO, IPA, employer).

480
300 TR3 Example: NM1✽PR✽2✽ACE INSURANCE COMPANY✽✽✽✽✽PI✽87728~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038
Entity ID Entity Type Name Last/ Name Name Name
NM1 ✽
Code
✽
Qualifier
✽
Org Name
✽
First
✽
Middle
✽
Prefix
M1 ID 2/3 M1 ID 1/1 X1 AN 1/60 O1 AN 1/35 O1 AN 1/25 O1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

Name ID Code ID Entity Entity ID Name Last/
✽ ✽ ✽ ✽ ✽ ✽ ~
Suffix Qualifier Code Relat Code Code Org Name
O1 AN 1/10 X1 ID 1/2 X1 AN 2/80 X1 ID 2/2 O1 ID 2/3 O1 AN 1/60

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED NM101 98 Entity Identifier Code M1 ID 2/3

Code identifying an organizational entity, a physical location, property or an
individual

OD: 271B1_2100A_NM101__EntityIdentifierCode

CODE DEFINITION

2B Third-Party Administrator
36 Employer
GP Gateway Provider
P5 Plan Sponsor
PR Payer

218 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100A • NM1
TECHNICAL REPORT • TYPE 3 INFORMATION SOURCE NAME

REQUIRED NM102 1065 Entity Type Qualifier M1 ID 1/1

Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.

OD: 271B1_2100A_NM102__EntityTypeQualifier

300440 Use this code to indicate whether the entity is an individual person
or an organization.
CODE DEFINITION

1 Person
2 Non-Person Entity
REQUIRED NM103 1035 Name Last or Organization Name X1 AN 1/60
Individual last name or organizational name
SYNTAX: C1203

OD:
271B1_2100A_NM103__InformationSourceLastorOrganizationName

IMPLEMENTATION NAME: Information Source Last or Organization Name

300563 Use this name for the organization name if NM102 is “2”.
Otherwise, this will be the individual’s last name.
SITUATIONAL NM104 1036 Name First O 1 AN 1/35
Individual first name

300645 SITUATIONAL RULE: Required when NM102 is “1”. If not required by this
implementation guide, do not send.

OD: 271B1_2100A_NM104__InformationSourceFirstName

IMPLEMENTATION NAME: Information Source First Name

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25
Individual middle name or initial

300931 SITUATIONAL RULE: Required when NM102 is “1" and the identifier in
2100A NM109 and Last Name in 2100A NM103 and First Name in
2100A NM104 and Name Suffix in 2100A NM107 if sent, are not
sufficient to identify the source of eligibility or benefit information.
If not required by this implementation guide, may be provided at
sender’s discretion, but cannot be required by the receiver.

OD: 271B1_2100A_NM105__InformationSourceMiddleName

IMPLEMENTATION NAME: Information Source Middle Name

NOT USED NM106 1038 Name Prefix O 1 AN 1/10

APRIL 2008 219

005010X279 • 271 • 2100A • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION SOURCE NAME TECHNICAL REPORT • TYPE 3

SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10

Suffix to individual name

300646 SITUATIONAL RULE: Required when NM102 is “1" and the identifier in
2100A NM109 and Last Name in 2100A NM103 and First Name in
2100A NM104 and Middle Name in 2100A NM105 if sent, are not
sufficient to identify the source of eligibility or benefit information.
If not required by this implementation guide, may be provided at
sender’s discretion, but cannot be required by the receiver.

OD: 271B1_2100A_NM107__InformationSourceNameSuffix

IMPLEMENTATION NAME: Information Source Name Suffix

REQUIRED NM108 66 Identification Code Qualifier X1 ID 1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX: P0809

OD: 271B1_2100A_NM108__IdentificationCodeQualifier

300607 Use code value “XV” if the Information Source is a Payer and the
National PlanID is mandated for use. Use code value “XX” if the
information source is a provider and the CMS National Provider
Identifier is mandated for use. Otherwise one of the other
appropriate code values may be used.
CODE DEFINITION

24 Employer’s Identification Number

46 Electronic Transmitter Identification Number (ETIN)
FI Federal Taxpayer’s Identification Number
NI National Association of Insurance Commissioners
(NAIC) Identification
PI Payor Identification
XV Centers for Medicare and Medicaid Services PlanID
CODE SOURCE 540: Centers for Medicare and Medicaid Services
PlanID
XX Centers for Medicare and Medicaid Services
National Provider Identifier
CODE SOURCE 537: Centers for Medicare & Medicaid Services
National Provider Identifier
REQUIRED NM109 67 Identification Code X1 AN 2/80
Code identifying a party or other code
SYNTAX: P0809

OD: 271B1_2100A_NM109__InformationSourcePrimaryIdentifier

IMPLEMENTATION NAME: Information Source Primary Identifier

NOT USED NM110 706 Entity Relationship Code X1 ID 2/2
NOT USED NM111 98 Entity Identifier Code O1 ID 2/3
NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

220 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100A • PER
TECHNICAL REPORT • TYPE 3 INFORMATION SOURCE CONTACT INFORMATION
ADMINISTRATIVE COMMUNICATIONS CONTACT 005010X279 • 271
INFORMATION • 2100A
SOURCE • PER INFORMATION
CONTACT
PER

SEGMENT DETAIL
526
300
PER - INFORMATION SOURCE CONTACT
INFORMATION
X12 Segment Name: Administrative Communications Contact
X12 Purpose: To identify a person or office to whom administrative communications should be
directed
X12 Syntax: 1. P0304
If either PER03 or PER04 is present, then the other is required.
2. P0506
If either PER05 or PER06 is present, then the other is required.
3. P0708
If either PER07 or PER08 is present, then the other is required.
Loop: 2100A — INFORMATION SOURCE NAME

Segment Repeat: 3

Usage: SITUATIONAL

48
10
30 Situational Rule: Required when the Information Source desires to advise the Information
Receiver on how to contact the Information Source about this eligibility
response. If not required by this implementation guide, may be provided
at the sender’s discretion, but cannot be required by the receiver.

702
300 TR3 Notes: 1. If this segment is used, at a minimum either PER02 must be used or
PER03 and PER04 must be used. It is recommended that at least
PER02, PER03 and PER04 are sent if this segment is used.

706
300 2. When the communication number represents a telephone number in
the United States and other countries using the North American
Dialing Plan (for voice, data, fax, etc.), the communication number
should always include the area code and phone number using the
format AAABBBCCCC. Where AAA is the area code, BBB is the
telephone number prefix, and CCCC is the telephone number (e.g.
(534)224-2525 would be represented as 5342242525). The extension,
when applicable, should be included in the communication number
immediately after the telephone number.

481
300 TR3 Example: PER✽IC✽MEMBER SERVICES✽TE✽8005551654✽FX✽2128769304~

486
300 TR3 Example: PER✽IC✽BILLING DEPT✽TE✽2128763654✽EX✽2104✽FX✽2128769304~

APRIL 2008 221

005010X279 • 271 • 2100A • PER ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION SOURCE CONTACT INFORMATION TECHNICAL REPORT • TYPE 3

DIAGRAM

PER01 366 PER02 93 PER03 365 PER04 364 PER05 365 PER06 364
Contact Name Comm Comm Comm Comm
PER ✽ Funct Code
✽ ✽
Number Qual
✽
Number
✽
Number Qual
✽
Number
M1 ID 2/2 O1 AN 1/60 X1 ID 2/2 X1 AN 1/256 X1 ID 2/2 X1 AN 1/256

PER07 365 PER08 364 PER09 443

Comm Comm Contact Inq
✽ ✽ ✽ ~
Number Qual Number Reference
X1 ID 2/2 X1 AN 1/256 O1 AN 1/20

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PER01 366 Contact Function Code M1 ID 2/2

Code identifying the major duty or responsibility of the person or group named

OD: 271B1_2100A_PER01__ContactFunctionCode

300457 Use this code to specify the type of person or group to which the
contact number applies.
CODE DEFINITION

IC Information Contact
SITUATIONAL PER02 93 Name O 1 AN 1/60
Free-form name

300458 SITUATIONAL RULE: Required when it is necessary to identify an

individual or other contact point to discuss information related to
this transaction. If not required by this implementation guide, do
not send.

OD: 271B1_2100A_PER02__InformationSourceContactName

IMPLEMENTATION NAME: Information Source Contact Name

301031 Use this data element when the name of the individual to contact is
not already defined or is different than the name within the prior
name segment (e.g. N1 or NM1).

SITUATIONAL PER03 365 Communication Number Qualifier X1 ID 2/2

Code identifying the type of communication number
SYNTAX: P0304

300932 SITUATIONAL RULE: Required

when a contact communication number, e-
mail or Web address is to be transmitted. If not required by this
implementation guide, do not send.

OD: 271B1_2100A_PER03__CommunicationNumberQualifier

300459 Use this code to specify what type of communication number is

following.
CODE DEFINITION

ED Electronic Data Interchange Access Number

EM Electronic Mail

222 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100A • PER
TECHNICAL REPORT • TYPE 3 INFORMATION SOURCE CONTACT INFORMATION

FX Facsimile
TE Telephone
UR Uniform Resource Locator (URL)
SITUATIONAL PER04 364 Communication Number X1 AN 1/256
Complete communications number including country or area code when
applicable
SYNTAX: P0304

300933 SITUATIONAL RULE: Required when PER02 is not present or when a

contact number, e-mail or Web address is to be sent in addition to
the contact name. If not required by this implementation guide, do
not send.

OD:
271B1_2100A_PER04__InformationSourceCommunicationNumber

IMPLEMENTATION NAME: Information Source Communication Number

300715 Use this for the communication number or URL as qualified by the
preceding data element.

300514 The format for US domestic phone numbers is:

AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number
SITUATIONAL PER05 365 Communication Number Qualifier X1 ID 2/2
Code identifying the type of communication number
SYNTAX: P0506

300934 SITUATIONAL RULE: Required

when a second communication contact
number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD: 271B1_2100A_PER05__CommunicationNumberQualifier

300459 Use this code to specify what type of communication number is

following.
CODE DEFINITION

ED Electronic Data Interchange Access Number

EM Electronic Mail
EX Telephone Extension
FX Facsimile
TE Telephone
UR Uniform Resource Locator (URL)

APRIL 2008 223

005010X279 • 271 • 2100A • PER ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION SOURCE CONTACT INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL PER06 364 Communication Number X1 AN 1/256

Complete communications number including country or area code when
applicable
SYNTAX: P0506

300934 SITUATIONAL RULE: Required

when a second communication contact
number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD:
271B1_2100A_PER06__InformationSourceCommunicationNumber

IMPLEMENTATION NAME: Information Source Communication Number

300514 The format for US domestic phone numbers is:

AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number

300715 Use this for the communication number or URL as qualified by the
preceding data element.
SITUATIONAL PER07 365 Communication Number Qualifier X1 ID 2/2
Code identifying the type of communication number
SYNTAX: P0708

300935 SITUATIONAL RULE: Required

when a third communication contact
number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD: 271B1_2100A_PER07__CommunicationNumberQualifier

300459 Use this code to specify what type of communication number is

following.
CODE DEFINITION

ED Electronic Data Interchange Access Number

EM Electronic Mail
EX Telephone Extension
FX Facsimile
TE Telephone
UR Uniform Resource Locator (URL)

224 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100A • PER
TECHNICAL REPORT • TYPE 3 INFORMATION SOURCE CONTACT INFORMATION

SITUATIONAL PER08 364 Communication Number X1 AN 1/256

Complete communications number including country or area code when
applicable
SYNTAX: P0708

300935 SITUATIONAL RULE: Required

when a third communication contact
number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD:
271B1_2100A_PER08__InformationSourceCommunicationNumber

IMPLEMENTATION NAME: Information Source Communication Number

300514 The format for US domestic phone numbers is:

AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number

300715 Use this for the communication number or URL as qualified by the
preceding data element.
NOT USED PER09 443 Contact Inquiry Reference O 1 AN 1/20

APRIL 2008 225

 005010X279 • 271 • 2100A • AAA ASC X12N • INSURANCE SUBCOMMITTEE
REQUEST VALIDATION TECHNICAL REPORT • TYPE 3
REQUEST VALIDATION 005010X279 • 271 • 2100A • AAA
REQUEST VALIDATION
AAA

SEGMENT DETAIL
589
300
AAA - REQUEST VALIDATION
X12 Segment Name: Request Validation
X12 Purpose: To specify the validity of the request and indicate follow-up action authorized
Loop: 2100A — INFORMATION SOURCE NAME

Segment Repeat: 9

Usage: SITUATIONAL

16
07
30 Situational Rule: Required when the request could not be processed at a system or
application level when specifically related to the information source data
contained in the original 270 transaction’s information source name loop
(Loop 2100A) or to indicate that the information source itself is
experiencing system problems and to indicate what action the originator
of the request transaction should take. If not required by this
implementation guide, do not send.

717
300 TR3 Notes: 1. Use this segment to indicate problems in processing the transaction
specifically related to the information source data contained in the
original 270 transaction’s information source name loop (Loop 2100A)
or to indicate that the information source itself is experiencing system
problems.

479
300 TR3 Example: AAA✽Y✽✽42✽Y~

DIAGRAM

AAA01 1073 AAA02 559 AAA03 901 AAA04 889

✽ Yes/No Cond ✽ Agency Reject Follow-up

AAA Resp Code Qual Code
✽
Reason Code
✽
Act Code ~
M1 ID 1/1 O1 ID 2/2 O1 ID 2/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED AAA01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: AAA01 designates whether the request is valid or invalid. Code “Y”
indicates that the code is valid; code “N” indicates that the code is invalid.

OD: 271B1_2100A_AAA01__ValidRequestIndicator

IMPLEMENTATION NAME: Valid Request Indicator

CODE DEFINITION

N No
300608 Use this code to indicate that the request or an
element in the request is not valid. The transaction
has been rejected as identified by the code in
AAA03.

226 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100A • AAA
TECHNICAL REPORT • TYPE 3 REQUEST VALIDATION

Y Yes
300609 Use this code to indicate that the request is valid,
however the transaction has been rejected as
identified by the code in AAA03.
NOT USED AAA02 559 Agency Qualifier Code O1 ID 2/2
REQUIRED AAA03 901 Reject Reason Code O1 ID 2/2
Code assigned by issuer to identify reason for rejection

OD: 271B1_2100A_AAA03__RejectReasonCode

300438 Use this code for the reason why the transaction was unable to be
processed successfully. This may indicate problems with the
system, the application, or the data content.
CODE DEFINITION

04 Authorized Quantity Exceeded

300766 Use this code to indicate that the transaction
exceeds the number of patient requests allowed by
the Information Source identified in Loop 2100A.
See section 1.4.3 Batch and Real Time for more
information regarding the number of patient
requests allowed in a transaction.
41 Authorization/Access Restrictions
300718 Use this code to indicate that the entity identified in
ISA06 or GS02 is not authorized to submit 270
transactions to the Information Source Identified in
Loop 2100A.
42 Unable to Respond at Current Time
300719 Use this code to indicate that Information Source
Identified in Loop 2100A is unable to process the
transaction at the current time. This indicates that
there is a problem within the Information Source’s
system.
79 Invalid Participant Identification
300720 Use this code to indicate that Information Source
Identified in Loop 2100A is invalid. If the transaction
is processed by a clearing house, VAN, etc., use this
code to indicate that the Information Source
Identified in Loop 2100A is not a valid identifier for
Information Sources the clearing house, VAN, etc.
have access to. If the transaction is sent directly to
the Information Source, use this code to indicate
that the Information Source Identified in Loop 2100A
is not a valid identifier.
80 No Response received - Transaction Terminated
300721 Use this code only if the transaction is processed by
a clearing house, VAN, etc. Use this code to indicate
that the transaction was sent to the Information
Source identified in Loop 2100A however no
response was received in the expected time frame.

This code must not be used by the Information

Source identified in Loop 2100A.

APRIL 2008 227

005010X279 • 271 • 2100A • AAA ASC X12N • INSURANCE SUBCOMMITTEE
REQUEST VALIDATION TECHNICAL REPORT • TYPE 3

T4 Payer Name or Identifier Missing

300722 Use this code to indicate that either the name or
identifier for Information Source Identified in Loop
2100A is missing.
REQUIRED AAA04 889 Follow-up Action Code O1 ID 1/1
Code identifying follow-up actions allowed

OD: 271B1_2100A_AAA04__FollowupActionCode

300437 Use this code to instruct the recipient of the 271 about what action
needs to be taken, if any, based on the validity code and the reject
reason code (if applicable).
CODE DEFINITION

C Please Correct and Resubmit

N Resubmission Not Allowed
P Please Resubmit Original Transaction
R Resubmission Allowed
S Do Not Resubmit; Inquiry Initiated to a Third Party
W Please Wait 30 Days and Resubmit
X Please Wait 10 Days and Resubmit
Y Do Not Resubmit; We Will Hold Your Request and
Respond Again Shortly

228 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000B • HL
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER LEVEL
HIERARCHICAL LEVEL 005010X279
INFORMATION• 271 • 2000B LEVEL
RECEIVER • HL
HL

SEGMENT DETAIL
527
300
HL - INFORMATION RECEIVER LEVEL
X12 Segment Name: Hierarchical Level
X12 Purpose: To identify dependencies among and the content of hierarchically related
groups of data segments
X12 Comments: 1. The HL segment is used to identify levels of detail information using a
hierarchical structure, such as relating line-item data to shipment data, and
packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
Loop: 2000B — INFORMATION RECEIVER LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: SITUATIONAL

60
08
30 Situational Rule: Required unless the 271 response contains an AAA segment in loop
2000A or 2100A. If not required by this implementation guide, may be
provided at sender’s discretion but cannot be required by the receiver.

436
300 TR3 Notes: 1. Use this segment to identify the hierarchical or entity level of
information being conveyed. The HL structure allows for the efficient
nesting of related occurrences of information. The developers’ intent
is to clearly identify the relationship of the patient to the subscriber
and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient)

can be grouped together under the same provider or the information
for multiple providers or information receivers can be grouped
together for the same payer or information source. See Section 1.3.2
for limitations on the number of occurrences of patients.

505
300 2. An example of the overall structure of the transaction set when used
in batch mode is:

Information Source Loop 2000A

Information Receiver Loop 2000B
Subscriber Loop 2000C
Dependent Loop 2000D
Eligibility or Benefit Information
Subscriber Loop 2000C
Eligibility or Benefit Information
Dependent Loop 2000D
Eligibility or Benefit Information

482
300 TR3 Example: HL✽2✽1✽21✽1~

APRIL 2008 229

005010X279 • 271 • 2000B • HL ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER LEVEL TECHNICAL REPORT • TYPE 3

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736

Hierarch Hierarch Hierarch Hierarch
HL ✽ ID Number
✽
Parent ID
✽
Level Code
✽
Child Code
~
M1 AN 1/12 O1 AN 1/12 M1 ID 1/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HL01 628 Hierarchical ID Number M 1 AN 1/12

A unique number assigned by the sender to identify a particular data segment in
a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence
of the HL segment in the transaction set. For example, HL01 could be used to
indicate the number of occurrences of the HL segment, in which case the value of
HL01 would be “1" for the initial HL segment and would be incremented by one in
each subsequent HL segment within the transaction.

OD: 271B1_2000B_HL01__HierarchicalIDNumber

300447 Use the sequentially assigned positive number to identify each

specific occurrence of an HL segment within a transaction set. The
first HL segment in the transaction should begin with the number
one and be incremented by one for each successive occurrence of
the HL segment within that specific transaction set (ST through SE).

300723 An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~
REQUIRED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12
Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which
the current HL segment is subordinate.

OD: 271B1_2000B_HL02__HierarchicalParentIDNumber

300887 Use this ID number to identify the specific Information Source to

which this Information Receiver is subordinate.

230 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000B • HL
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER LEVEL

REQUIRED HL03 735 Hierarchical Level Code M1 ID 1/2

Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the
current HL segment up to the next occurrence of an HL segment in the
transaction. For example, HL03 is used to indicate that subsequent segments in
the HL loop form a logical grouping of data referring to shipment, order, or item-
level information.

OD: 271B1_2000B_HL03__HierarchicalLevelCode

300888 All data that follows this HL segment is associated with the
Information Receiver identified by the level code. This association
continues until the next occurrence of an HL segment.
CODE DEFINITION

21 Information Receiver
REQUIRED HL04 736 Hierarchical Child Code O1 ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL
segments related to the current HL segment.

OD: 271B1_2000B_HL04__HierarchicalChildCode

300503 Use this code to indicate whether there are additional hierarchical
levels subordinate to the current hierarchical level.
CODE DEFINITION

0 No Subordinate HL Segment in This Hierarchical

Structure.
1 Additional Subordinate HL Data Segment in This
Hierarchical Structure.

APRIL 2008 231

 005010X279 • 271 • 2100B • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER NAME TECHNICAL REPORT • TYPE 3
INDIVIDUAL OR ORGANIZATIONAL NAME 005010X279
INFORMATION• 271 • 2100B NAME
RECEIVER • NM1
NM1

SEGMENT DETAIL
528
300
NM1 - INFORMATION RECEIVER NAME
X12 Segment Name: Individual or Organizational Name
X12 Purpose: To supply the full name of an individual or organizational entity
X12 Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
3. C1203
If NM112 is present, then NM103 is required.
Loop: 2100B — INFORMATION RECEIVER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

464
300 TR3 Notes: 1. Use this segment to identify an entity by name and/or identification
number. This NM1 loop is used to identify the eligibility/benefit
information receiver (e.g., provider, medical group, IPA, or hospital).

488
300 TR3 Example: NM1✽1P✽1✽JONES✽MARCUS✽✽✽MD✽34✽111223333~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038
Entity ID Entity Type Name Last/ Name Name Name
NM1 ✽
Code
✽
Qualifier
✽
Org Name
✽
First
✽
Middle
✽
Prefix
M1 ID 2/3 M1 ID 1/1 X1 AN 1/60 O1 AN 1/35 O1 AN 1/25 O1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

Name ID Code ID Entity Entity ID Name Last/
✽ ✽ ✽ ✽ ✽ ✽ ~
Suffix Qualifier Code Relat Code Code Org Name
O1 AN 1/10 X1 ID 1/2 X1 AN 2/80 X1 ID 2/2 O1 ID 2/3 O1 AN 1/60

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED NM101 98 Entity Identifier Code M1 ID 2/3

Code identifying an organizational entity, a physical location, property or an
individual

OD: 271B1_2100B_NM101__EntityIdentifierCode

CODE DEFINITION

1P Provider
2B Third-Party Administrator
36 Employer
80 Hospital
FA Facility

232 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100B • NM1
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER NAME

GP Gateway Provider
P5 Plan Sponsor
PR Payer
REQUIRED NM102 1065 Entity Type Qualifier M1 ID 1/1
Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.

OD: 271B1_2100B_NM102__EntityTypeQualifier

300440 Use this code to indicate whether the entity is an individual person
or an organization.
CODE DEFINITION

1 Person
2 Non-Person Entity
SITUATIONAL NM103 1035 Name Last or Organization Name X1 AN 1/60
Individual last name or organizational name
SYNTAX: C1203

300936 SITUATIONAL RULE: Required when this information was used from the
270 transaction to identify the Information Receiver. If not required
by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD:
271B1_2100B_NM103__InformationReceiverLastorOrganizationName

IMPLEMENTATION NAME: Information Receiver Last or Organization Name

300449 Use this name for the organization name if the entity type qualifier
is a non-person entity. Otherwise, this will be the individual’s last
name.

SITUATIONAL NM104 1036 Name First O 1 AN 1/35

Individual first name

300936 SITUATIONAL RULE: Required

when this information was used from the
270 transaction to identify the Information Receiver. If not required
by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100B_NM104__InformationReceiverFirstName

IMPLEMENTATION NAME: Information Receiver First Name

300937 Use this name only if NM102 is “1”.

APRIL 2008 233

005010X279 • 271 • 2100B • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER NAME TECHNICAL REPORT • TYPE 3

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25

Individual middle name or initial

300936 SITUATIONAL RULE: Required

when this information was used from the
270 transaction to identify the Information Receiver. If not required
by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100B_NM105__InformationReceiverMiddleName

IMPLEMENTATION NAME: Information Receiver Middle Name

300937 Use this name only if NM102 is “1”.

NOT USED NM106 1038 Name Prefix O 1 AN 1/10
SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10
Suffix to individual name

300936 SITUATIONAL RULE: Required when this information was used from the
270 transaction to identify the Information Receiver. If not required
by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100B_NM107__InformationReceiverNameSuffix

IMPLEMENTATION NAME: Information Receiver Name Suffix

301032 Use name suffix only if NM102 is “1”; e.g., Sr., Jr., or III.
REQUIRED NM108 66 Identification Code Qualifier X1 ID 1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX: P0809

OD: 271B1_2100B_NM108__IdentificationCodeQualifier

300567 Use this element to qualify the identification number submitted in

NM109. This is the number that the information source associates
with the information receiver. Because only one number can be
submitted in NM109, the following hierarchy must be used.
Additional identifiers are to be placed in the REF segment. If the
information receiver is a provider and the National Provider ID is
mandated for use and the provider is a covered health care
provider under the mandate, code value “XX” must be used.
Otherwise, one of the following codes may be used with the
following hierarchy applied: Use the first code that applies: “SV”,
“PP”, “FI”, “34". The code ”SV" is recommended to be used prior
to the mandated use of the National Provider ID. If the information
receiver is a payer and the CMS National PlanID is mandated for
use, code value “XV” must be used, otherwise, use code value “PI”.
If the information receiver is an employer, use code value “24".
CODE DEFINITION

24 Employer’s Identification Number

300568 Use this code only when the 270/271 transaction
sets are used by an employer inquiring about
eligibility and benefits of their employees.

234 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100B • NM1
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER NAME

34 Social Security Number

300658 The social security number may not be used for any
Federally administered programs such as Medicare.
FI Federal Taxpayer’s Identification Number
PI Payor Identification
300610 Use this code only when the information receiver is
a payer.
PP Pharmacy Processor Number
SV Service Provider Number
300611 Use this code for the identification number assigned
by the information source.
XV Centers for Medicare and Medicaid Services PlanID
CODE SOURCE 540: Centers for Medicare and Medicaid Services
PlanID
XX Centers for Medicare and Medicaid Services
National Provider Identifier
CODE SOURCE 537: Centers for Medicare & Medicaid Services
National Provider Identifier
REQUIRED NM109 67 Identification Code X1 AN 2/80
Code identifying a party or other code
SYNTAX: P0809

OD: 271B1_2100B_NM109__InformationReceiverIdentificationNumber

IMPLEMENTATION NAME: Information Receiver Identification Number

NOT USED NM110 706 Entity Relationship Code X1 ID 2/2
NOT USED NM111 98 Entity Identifier Code O1 ID 2/3
NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

APRIL 2008 235

 005010X279 • 271 • 2100B • REF ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3
REFERENCE INFORMATION 005010X279
INFORMATION• 271 • 2100B ADDITIONAL
RECEIVER • REF IDENTIFICATION
REF

SEGMENT DETAIL
529
300
REF - INFORMATION RECEIVER ADDITIONAL
IDENTIFICATION
X12 Segment Name: Reference Information
X12 Purpose: To specify identifying information
X12 Syntax: 1. R0203
At least one of REF02 or REF03 is required.
Loop: 2100B — INFORMATION RECEIVER NAME

Segment Repeat: 9

Usage: SITUATIONAL

36
09
30 Situational Rule: Required when this information was used from the 270 transaction to
identify the Information Receiver. If not required by this implementation
guide, may be provided at sender’s discretion but cannot be required by
the receiver.

724
300 TR3 Notes: 1. Use this segment when needed to convey other or additional
identification numbers for the information receiver. The type of
reference number is determined by the qualifier in REF01. Only one
occurrence of each REF01 code value may be used in the 2100B loop.

508
300 TR3 Example: REF✽EO✽477563928~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

Reference Reference
✽ Description ✽ Reference
REF ✽
Ident Qual
✽
Ident Identifier
~
M1 ID 2/3 X1 AN 1/50 X1 AN 1/80 O1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED REF01 128 Reference Identification Qualifier M1 ID 2/3

Code qualifying the Reference Identification

OD: 271B1_2100B_REF01__ReferenceIdentificationQualifier

300454 Use this code to specify or qualify the type of reference number
that is following in REF02, REF03, or both.

301049 Only one occurrence of each REF01 code value may be used in the
2100B loop.
CODE DEFINITION

0B State License Number

300806 The state assigning the license number must be
identified in REF03.
1C Medicare Provider Number

236 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100B • REF
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER ADDITIONAL IDENTIFICATION

1D Medicaid Provider Number

1J Facility ID Number
4A Personal Identification Number (PIN)
CT Contract Number
EL Electronic device pin number
EO Submitter Identification Number
HPI Centers for Medicare and Medicaid Services
National Provider Identifier
301101 The Centers for Medicare and Medicaid Services
National Provider Identifier may be used in this
segment prior to being mandated for use.
CODE SOURCE 537: Centers for Medicare & Medicaid Services
National Provider Identifier
JD User Identification
N5 Provider Plan Network Identification Number
N7 Facility Network Identification Number
Q4 Prior Identifier Number
SY Social Security Number
300658 The social security number may not be used for any
Federally administered programs such as Medicare.
TJ Federal Taxpayer’s Identification Number
REQUIRED REF02 127 Reference Identification X1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: R0203

OD: 271B1_2100B_REF02__InformationReceiverAdditionalIdentifier

IMPLEMENTATION NAME: Information Receiver Additional Identifier

300453 Use this information for the reference number as qualified by the
preceding data element (REF01).
SITUATIONAL REF03 352 Description X1 AN 1/80
A free-form description to clarify the related data elements and their content
SYNTAX: R0203

300938 SITUATIONAL RULE: Required when REF01 = “0B”. If not required by this
implementation guide, do not send.

OD:
271B1_2100B_REF03__InformationReceiverAdditionalIdentifierState

IMPLEMENTATION NAME: Information Receiver Additional Identifier State

300808 Use this element for the two character state code of the state
assigning the identifier supplied in REF02.

See Code source 22: States and Outlying Areas of the U.S.

NOT USED REF04 C040 REFERENCE IDENTIFIER O1

APRIL 2008 237

 005010X279 • 271 • 2100B • AAA ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER REQUEST VALIDATION TECHNICAL REPORT • TYPE 3
REQUEST VALIDATION 005010X279
INFORMATION• 271 • 2100B REQUEST
RECEIVER • AAA VALIDATION
AAA

SEGMENT DETAIL
590
300
AAA - INFORMATION RECEIVER REQUEST
VALIDATION
X12 Segment Name: Request Validation
X12 Purpose: To specify the validity of the request and indicate follow-up action authorized
Loop: 2100B — INFORMATION RECEIVER NAME

Segment Repeat: 9

Usage: SITUATIONAL

39
09
30 Situational Rule: Required when the request could not be processed at a system or
application level when specifically related to the information receiver data
contained in the original 270 transaction’s information receiver name loop
(Loop 2100B) and to indicate what action the originator of the request
transaction should take. If not required by this implementation guide, do
not send.

612
300 TR3 Notes: 1. Use this segment to indicate problems in processing the transaction
specifically related to the information receiver data contained in the
original 270 transaction’s information receiver name loop (Loop
2100B).

484
300 TR3 Example: AAA✽N✽✽43✽C~

DIAGRAM

AAA01 1073 AAA02 559 AAA03 901 AAA04 889

✽ Yes/No Cond ✽ Agency Reject Follow-up

AAA Resp Code Qual Code
✽
Reason Code
✽
Act Code ~
M1 ID 1/1 O1 ID 2/2 O1 ID 2/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED AAA01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: AAA01 designates whether the request is valid or invalid. Code “Y”
indicates that the code is valid; code “N” indicates that the code is invalid.

OD: 271B1_2100B_AAA01__ValidRequestIndicator

IMPLEMENTATION NAME: Valid Request Indicator

CODE DEFINITION

N No
300561 Use this code to indicate that the request or an
element in the request is not valid. The transaction
has been rejected as identified by the code in
AAA03.

238 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100B • AAA
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER REQUEST VALIDATION

Y Yes
300562 Use this code to indicate that the request is valid,
however the transaction has been rejected as
identified by the code in AAA03.
NOT USED AAA02 559 Agency Qualifier Code O1 ID 2/2
REQUIRED AAA03 901 Reject Reason Code O1 ID 2/2
Code assigned by issuer to identify reason for rejection

OD: 271B1_2100B_AAA03__RejectReasonCode

300438 Use this code for the reason why the transaction was unable to be
processed successfully. This may indicate problems with the
system, the application, or the data content.
CODE DEFINITION

15 Required application data missing

300659 Use this code only when the information receiver’s
additional identification is missing.
41 Authorization/Access Restrictions
43 Invalid/Missing Provider Identification
44 Invalid/Missing Provider Name
45 Invalid/Missing Provider Specialty
46 Invalid/Missing Provider Phone Number
47 Invalid/Missing Provider State
48 Invalid/Missing Referring Provider Identification
Number
50 Provider Ineligible for Inquiries
51 Provider Not on File
79 Invalid Participant Identification
300572 Use this code only when the information receiver is
not a provider or payer.
97 Invalid or Missing Provider Address
T4 Payer Name or Identifier Missing
300573 Use this code only when the information receiver is
a payer.
REQUIRED AAA04 889 Follow-up Action Code O1 ID 1/1
Code identifying follow-up actions allowed

OD: 271B1_2100B_AAA04__FollowupActionCode

300437 Use this code to instruct the recipient of the 271 about what action
needs to be taken, if any, based on the validity code and the reject
reason code (if applicable).
CODE DEFINITION

C Please Correct and Resubmit

N Resubmission Not Allowed
R Resubmission Allowed
S Do Not Resubmit; Inquiry Initiated to a Third Party
W Please Wait 30 Days and Resubmit
X Please Wait 10 Days and Resubmit

APRIL 2008 239

005010X279 • 271 • 2100B • AAA ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER REQUEST VALIDATION TECHNICAL REPORT • TYPE 3

Y Do Not Resubmit; We Will Hold Your Request and

Respond Again Shortly

240 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100B • PRV
TECHNICAL REPORT • TYPE 3 INFORMATION RECEIVER PROVIDER INFORMATION
PROVIDER INFORMATION 005010X279
INFORMATION• 271 • 2100B PROVIDER
RECEIVER • PRV INFORMATION
PRV

SEGMENT DETAIL
816
300
PRV - INFORMATION RECEIVER PROVIDER
INFORMATION
X12 Segment Name: Provider Information
X12 Purpose: To specify the identifying characteristics of a provider
X12 Syntax: 1. P0203
If either PRV02 or PRV03 is present, then the other is required.
Loop: 2100B — INFORMATION RECEIVER NAME

Segment Repeat: 1

Usage: SITUATIONAL

32
08
30 Situational Rule: Required when the 270 request contained a 2100B PRV segment and the
information contained in the PRV segment was used to determine the 271
response. If not required by this implementation guide, do not send.

831
300 TR3 Notes: 1. This segment is used to convey additional information about a
provider’s role in the eligibility/benefit being inquired about and who
is also the Information Receiver. For example, if the Information
Receiver is also the Referring Provider, this PRV segment would be
used to identify the provider’s role. This PRV segment applies to all
benefits returned for this Information Receiver unless overridden by a
PRV segment in the 2100C, 2120C, 2100D or 2120D loops.

746
300 2. PRV02 qualifies PRV03.

050
301 TR3 Example: PRV✽RF✽PXC✽207Q00000X~

DIAGRAM

PRV01 1221 PRV02 128 PRV03 127 PRV04 156 PRV05 C035 PRV06 1223
Provider Reference Reference State or Provider Provider
PRV ✽ Code
✽
Ident Qual
✽
Ident
✽
Prov Code
✽
Spec. Inf.
✽
Org Code ~
M1 ID 1/3 X1 ID 2/3 X1 AN 1/50 O1 ID 2/2 O1 O1 ID 3/3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PRV01 1221 Provider Code M1 ID 1/3

Code identifying the type of provider

OD: 271B1_2100B_PRV01__ProviderCode

CODE DEFINITION

AD Admitting
AT Attending
BI Billing
CO Consulting
CV Covering

APRIL 2008 241

005010X279 • 271 • 2100B • PRV ASC X12N • INSURANCE SUBCOMMITTEE
INFORMATION RECEIVER PROVIDER INFORMATION TECHNICAL REPORT • TYPE 3

H Hospital
HH Home Health Care
LA Laboratory
OT Other Physician
P1 Pharmacist
P2 Pharmacy
PC Primary Care Physician
PE Performing
R Rural Health Clinic
RF Referring
SB Submitting
SK Skilled Nursing Facility
SU Supervising
SITUATIONAL PRV02 128 Reference Identification Qualifier X1 ID 2/3
Code qualifying the Reference Identification
SYNTAX: P0203

300940 SITUATIONAL RULE: Required

when the 270 request contained a 2100B
PRV segment and the information contained in PRV02 and PRV03
was used to determine the 271 response. If not required by this
implementation guide, do not send.

OD: 271B1_2100B_PRV02__ReferenceIdentificationQualifier

CODE DEFINITION

PXC Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy
SITUATIONAL PRV03 127 Reference Identification X1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: P0203

300940 SITUATIONAL RULE: Required

when the 270 request contained a 2100B
PRV segment and the information contained in PRV02 and PRV03
was used to determine the 271 response. If not required by this
implementation guide, do not send.

OD: 271B1_2100B_PRV03__ReceiverProviderSpecialtyCode

IMPLEMENTATION NAME: Receiver Provider Specialty Code

300817 Use this number for the reference number as qualified by the
preceding data element (PRV02).
NOT USED PRV04 156 State or Province Code O1 ID 2/2
NOT USED PRV05 C035 PROVIDER SPECIALTY INFORMATION O1
NOT USED PRV06 1223 Provider Organization Code O1 ID 3/3

242 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000C • HL
TECHNICAL REPORT • TYPE 3 SUBSCRIBER LEVEL
HIERARCHICAL LEVEL SUBSCRIBER
005010X279 • 271 • 2000C • HL
LEVEL
HL

SEGMENT DETAIL
530
300
HL - SUBSCRIBER LEVEL
X12 Segment Name: Hierarchical Level
X12 Purpose: To identify dependencies among and the content of hierarchically related
groups of data segments
X12 Comments: 1. The HL segment is used to identify levels of detail information using a
hierarchical structure, such as relating line-item data to shipment data, and
packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
Loop: 2000C — SUBSCRIBER LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: SITUATIONAL

61
08
30 Situational Rule: Required unless the 271 response contains an AAA segment in loop
2000A, 2100A or 2100B. If not required by this implementation guide, may
be provided at sender’s discretion but cannot be required by the receiver.

436
300 TR3 Notes: 1. Use this segment to identify the hierarchical or entity level of
information being conveyed. The HL structure allows for the efficient
nesting of related occurrences of information. The developers’ intent
is to clearly identify the relationship of the patient to the subscriber
and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient)

can be grouped together under the same provider or the information
for multiple providers or information receivers can be grouped
together for the same payer or information source. See Section 1.3.2
for limitations on the number of occurrences of patients.

051
301 2. An example of the overall structure of the transaction set when used
in batch mode is:

Information Source Loop 2000A

Information Receiver Loop 2000B
Subscriber Loop 2000C
Dependent Loop 2000D
Eligibility or Benefit Information
Subscriber Loop 2000C
Eligibility or Benefit Information
Dependent Loop 2000D
Eligibility or Benefit Information

The above example shows 2 different Subscribers. The first

Subscriber is not the patient, only the dependent is the patient. The
second Subscriber is a patient and the Dependent is also a patient.

483
300 TR3 Example: HL✽3✽2✽22✽1~

APRIL 2008 243

005010X279 • 271 • 2000C • HL ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER LEVEL TECHNICAL REPORT • TYPE 3

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736

Hierarch Hierarch Hierarch Hierarch
HL ✽ ID Number
✽
Parent ID
✽
Level Code
✽
Child Code
~
M1 AN 1/12 O1 AN 1/12 M1 ID 1/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HL01 628 Hierarchical ID Number M 1 AN 1/12

A unique number assigned by the sender to identify a particular data segment in
a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence
of the HL segment in the transaction set. For example, HL01 could be used to
indicate the number of occurrences of the HL segment, in which case the value of
HL01 would be “1" for the initial HL segment and would be incremented by one in
each subsequent HL segment within the transaction.

OD: 271B1_2000C_HL01__HierarchicalIDNumber

300725 An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~
HL*3*2*22*1~
NM1*IL*1*SMITH*ROBERT*B***MI*11122333301~
HL*4*3*23*0~
NM1*03*1*SMITH*MARY*LOU~
Eligibility/Benefit Data
HL*5*2*22*0~
NM1*IL*1*BROWN*JOHN*E***MI*22211333301~
Eligibility/Benefit Data

300447 Use the sequentially assigned positive number to identify each

specific occurrence of an HL segment within a transaction set. The
first HL segment in the transaction should begin with the number
one and be incremented by one for each successive occurrence of
the HL segment within that specific transaction set (ST through SE).
REQUIRED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12
Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which
the current HL segment is subordinate.

OD: 271B1_2000C_HL02__HierarchicalParentIDNumber

300889 Use this ID number to identify the specific Information Receiver to

which this Subscriber is subordinate.

244 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000C • HL
TECHNICAL REPORT • TYPE 3 SUBSCRIBER LEVEL

REQUIRED HL03 735 Hierarchical Level Code M1 ID 1/2

Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the
current HL segment up to the next occurrence of an HL segment in the
transaction. For example, HL03 is used to indicate that subsequent segments in
the HL loop form a logical grouping of data referring to shipment, order, or item-
level information.

OD: 271B1_2000C_HL03__HierarchicalLevelCode

300890 All data that follows this HL segment is associated with the
Subscriber identified by the level code. This association continues
until the next occurrence of an HL segment.
CODE DEFINITION

22 Subscriber
300556 Use the subscriber level to identify the insured or
subscriber of the health care coverage. This entity
may or may not be the actual patient.
REQUIRED HL04 736 Hierarchical Child Code O1 ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL
segments related to the current HL segment.

OD: 271B1_2000C_HL04__HierarchicalChildCode

300574 Because of the hierarchical structure, the code value in the HL04 at
the Loop 2000C level should be “1" if a Loop 2000D level
(dependent) is associated with this subscriber. If no Loop 2000D
level exists for this subscriber, then the code value for HL04 should
be ”0" (zero).
CODE DEFINITION

0 No Subordinate HL Segment in This Hierarchical

Structure.
1 Additional Subordinate HL Data Segment in This
Hierarchical Structure.

APRIL 2008 245

 005010X279 • 271 • 2000C • TRN ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER TRACE NUMBER TECHNICAL REPORT • TYPE 3
TRACE SUBSCRIBER
005010X279 • 271 • 2000C
TRACE • TRN
NUMBER
TRN

SEGMENT DETAIL
531
300
TRN - SUBSCRIBER TRACE NUMBER
X12 Segment Name: Trace
X12 Purpose: To uniquely identify a transaction to an application
X12 Set Notes: 1. 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.
Loop: 2000C — SUBSCRIBER LEVEL

Segment Repeat: 3

Usage: SITUATIONAL

41
09
30 Situational Rule: Required when the 270 request contained one or two TRN segments and
the subscriber is the patient (See Section 1.4.2.). One TRN segment for
each TRN submitted in the 270 must be returned.
OR
Required when the Information Source needs to return a unique trace
number for the current transaction.
If not required by this implementation guide, do not send.

862
300 TR3 Notes: 1. An information source may receive up to two TRN segments in each
loop 2000C of a 270 transaction and must return each of them in loop
2000C of the 271 transaction unless the person submitted in loop
2000C is determined to be a dependent, then the TRN segments must
be returned in loop 2000D. See Section 1.4.2. The returned TRN
segments will have a value of “2” in TRN01. See Section 1.4.6
Information Linkage for additional information.

811
300 2. If the subscriber is the patient, an information source may add one
TRN segment to loop 2000C with a value of “1" in TRN01 and must
identify themselves in TRN03.

863
300 3. This segment must not be used if the subscriber is not the patient.
See section 1.4.2. Basic Concepts.

660
300 4. If this transaction passes through a clearinghouse, the clearinghouse
will receive from the information source the information receiver’s
TRN segment and the clearinghouse’s TRN segment with a value of
“2" in TRN01. Since the ultimate destination of the transaction is the
information receiver, if the clearinghouse intends on passing their
TRN segment to the information receiver, the clearinghouse must
change the value in TRN01 to ”1" of their TRN segment. This must be
done since the trace number in the clearinghouse’s TRN segment is
not actually a referenced transaction trace number to the information
receiver.

246 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000C • TRN
TECHNICAL REPORT • TYPE 3 SUBSCRIBER TRACE NUMBER

052
301 5. The trace number in the 271 transaction TRN02 must be returned
exactly as submitted in the 270 transaction. For example, if the 270
transaction TRN02 was 012345678 it must be returned as 012345678
and not as 12345678.

661
300 TR3 Example: TRN✽2✽98175-012547✽9877281234✽RADIOLOGY~
TRN✽2✽109834652831✽9XYZCLEARH✽REALTIME~
TRN✽1✽209991094361✽9ABCINSURE~

The above example represents how an information source would respond.

The first TRN segment was initiated by the information receiver. The
second TRN segment was initiated by the clearinghouse. The third TRN
segment was initiated by the information source.

703
300 TR3 Example: TRN✽2✽98175-012547✽9877281234✽RADIOLOGY~
TRN✽1✽109834652831✽9XYZCLEARH✽REALTIME~
TRN✽1✽209991094361✽9ABCINSURE~

The above example represents how a clearinghouse would respond to the

same set of TRN segments if the clearinghouse intends to pass their TRN
segment on to the information receiver. If the clearinghouse does not
intend to pass their TRN segment on to the information receiver, only the
first and third TRN segments in the example would be sent.

DIAGRAM

TRN01 481 TRN02 127 TRN03 509 TRN04 127

Trace Type Reference
✽ Originating ✽ Reference
TRN ✽ Code
✽
Ident Company ID Ident
~
M1 ID 1/2 M1 AN 1/50 O1 AN 10/10 O1 AN 1/50

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED TRN01 481 Trace Type Code M1 ID 1/2

Code identifying which transaction is being referenced

OD: 271B1_2000C_TRN01__TraceTypeCode

CODE DEFINITION

1 Current Transaction Trace Numbers

300662 The term “Current Transaction Trace Numbers”
refers to trace or reference numbers assigned by
the creator of the 271 transaction (the information
source).

If a clearinghouse has assigned a TRN segment and

intends on returning their TRN segment in the 271
response to the information receiver, they must
convert the value in TRN01 to “1" (since it will be
returned by the information source as a ”2").

APRIL 2008 247

005010X279 • 271 • 2000C • TRN ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER TRACE NUMBER TECHNICAL REPORT • TYPE 3

2 Referenced Transaction Trace Numbers

300557 The term “Referenced Transaction Trace Numbers”
refers to trace or reference numbers originally sent
in the 270 transaction and now returned in the 271.
REQUIRED TRN02 127 Reference Identification M 1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SEMANTIC: TRN02 provides unique identification for the transaction.

OD: 271B1_2000C_TRN02__TraceNumber

IMPLEMENTATION NAME: Trace Number

301053 This element must contain the trace number submitted in TRN02
from the 270 transaction and must be returned exactly as
submitted.

REQUIRED TRN03 509 Originating Company Identifier O 1 AN 10/10

A unique identifier designating the company initiating the funds transfer
instructions, business transaction or assigning tracking reference identification.
SEMANTIC: TRN03 identifies an organization.

OD: 271B1_2000C_TRN03__TraceAssigningEntityIdentifier

IMPLEMENTATION NAME: Trace Assigning Entity Identifier

300664 If TRN01 is “1”, use this information to identify the organization

that assigned this trace number.

301102 If TRN01 is “2", this is the value received in the original 270
transaction.

300665 The first position must be either a “1” if an EIN is used, a “3” if a
DUNS is used or a “9” if a user assigned identifier is used.
SITUATIONAL TRN04 127 Reference Identification O 1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SEMANTIC: TRN04 identifies a further subdivision within the organization.

300942 SITUATIONAL RULE: Requiredwhen TRN01 = “2" and this element was
used in the corresponding 270 TRN segment.
OR
Required when TRN01 = ”1" and the Information Source needs to
further identify a specific component, such as a specific division or
group of the entity identified in the previous data element (TRN03).
If not required by this implementation guide, do not send.

OD: 271B1_2000C_TRN04__TraceAssigningEntityAdditionalIdentifier

IMPLEMENTATION NAME: Trace Assigning Entity Additional Identifier

248 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • NM1
TECHNICAL REPORT • TYPE 3 SUBSCRIBER NAME
INDIVIDUAL OR ORGANIZATIONAL NAME 005010X279
SUBSCRIBER • 271
NAME• 2100C • NM1
NM1

SEGMENT DETAIL
532
300
NM1 - SUBSCRIBER NAME
X12 Segment Name: Individual or Organizational Name
X12 Purpose: To supply the full name of an individual or organizational entity
X12 Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
3. C1203
If NM112 is present, then NM103 is required.
Loop: 2100C — SUBSCRIBER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

667
300 TR3 Notes: 1. Use this segment to identify an entity by name and/or identification
number. This NM1 loop is used to identify the insured or subscriber.

613
300 TR3 Example: NM1✽IL✽1✽SMITH✽JOHN✽L✽✽✽MI✽44411555501~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038
Entity ID Entity Type Name Last/ Name Name Name
NM1 ✽
Code
✽
Qualifier
✽
Org Name
✽
First
✽
Middle
✽
Prefix
M1 ID 2/3 M1 ID 1/1 X1 AN 1/60 O1 AN 1/35 O1 AN 1/25 O1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

Name ID Code ID Entity Entity ID Name Last/
✽ ✽ ✽ ✽ ✽ ✽ ~
Suffix Qualifier Code Relat Code Code Org Name
O1 AN 1/10 X1 ID 1/2 X1 AN 2/80 X1 ID 2/2 O1 ID 2/3 O1 AN 1/60

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED NM101 98 Entity Identifier Code M1 ID 2/3

Code identifying an organizational entity, a physical location, property or an
individual

OD: 271B1_2100C_NM101__EntityIdentifierCode

CODE DEFINITION

IL Insured or Subscriber

APRIL 2008 249

005010X279 • 271 • 2100C • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER NAME TECHNICAL REPORT • TYPE 3

REQUIRED NM102 1065 Entity Type Qualifier M1 ID 1/1

Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.

OD: 271B1_2100C_NM102__EntityTypeQualifier

CODE DEFINITION

1 Person
SITUATIONAL NM103 1035 Name Last or Organization Name X1 AN 1/60
Individual last name or organizational name
SYNTAX: C1203

300669 SITUATIONAL RULE: Required unless a rejection response is generated

and this element was not valued in the request.
If not required by this implementation guide, do not send.

OD: 271B1_2100C_NM103__SubscriberLastName

IMPLEMENTATION NAME: Subscriber Last Name

300506 Use this name for the subscriber’s last name.

SITUATIONAL NM104 1036 Name First O 1 AN 1/35

Individual first name

300669 SITUATIONAL RULE: Required unless a rejection response is generated

and this element was not valued in the request.
If not required by this implementation guide, do not send.

OD: 271B1_2100C_NM104__SubscriberFirstName

IMPLEMENTATION NAME: Subscriber First Name

300450 Use this name for the subscriber’s first name.

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25

Individual middle name or initial

300670 SITUATIONAL RULE: Requiredwhen the Information Source requires this

information to identify the Subscriber for subsequent EDI
transactions (see Section 1.4.7) unless a rejection response is
generated and this element was not valued in the request. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100C_NM105__SubscriberMiddleNameorInitial

IMPLEMENTATION NAME: Subscriber Middle Name or Initial

300451 Use this name for the subscriber’s middle name or initial.
NOT USED NM106 1038 Name Prefix O 1 AN 1/10

250 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • NM1
TECHNICAL REPORT • TYPE 3 SUBSCRIBER NAME

SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10

Suffix to individual name

300670 SITUATIONAL RULE: Requiredwhen the Information Source requires this

information to identify the Subscriber for subsequent EDI
transactions (see Section 1.4.7) unless a rejection response is
generated and this element was not valued in the request. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100C_NM107__SubscriberNameSuffix

IMPLEMENTATION NAME: Subscriber Name Suffix

300452 Use this for the suffix to an individual’s name; e.g., Sr., Jr., or III.

SITUATIONAL NM108 66 Identification Code Qualifier X1 ID 1/2

Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX: P0809

300669 SITUATIONAL RULE: Required unless a rejection response is generated

and this element was not valued in the request.
If not required by this implementation guide, do not send.

OD: 271B1_2100C_NM108__IdentificationCodeQualifier

300630 Use this element to qualify the identification number submitted in

NM109. This is the primary number that the information source
associates with the subscriber.
CODE DEFINITION

II Standard Unique Health Identifier for each Individual

in the United States
301054 Under the Health Insurance Portability and
Accountability Act of 1996, the Secretary of the
Department of Health and Human Services may
adopt a standard individual identifier for use in this
transaction.
MI Member Identification Number
300668 This code may only be used prior to the mandated
use of code “II”. This is the unique number the
payer or information source uses to identify the
insured (e.g., Health Insurance Claim Number,
Medicaid Recipient ID Number, HMO Member ID,
etc.).

APRIL 2008 251

005010X279 • 271 • 2100C • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER NAME TECHNICAL REPORT • TYPE 3

SITUATIONAL NM109 67 Identification Code X1 AN 2/80

Code identifying a party or other code
SYNTAX: P0809

300669 SITUATIONAL RULE: Requiredunless a rejection response is generated

and this element was not valued in the request.
If not required by this implementation guide, do not send.

OD: 271B1_2100C_NM109__SubscriberPrimaryIdentifier

IMPLEMENTATION NAME: Subscriber Primary Identifier

300448 Use this code for the reference number as qualified by the
preceding data element (NM108).

NOT USED NM110 706 Entity Relationship Code X1 ID 2/2

NOT USED NM111 98 Entity Identifier Code O1 ID 2/3
NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

252 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • REF
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ADDITIONAL IDENTIFICATION
REFERENCE INFORMATION SUBSCRIBER
005010X279 • 271 • 2100C •IDENTIFICATION
ADDITIONAL REF
REF

SEGMENT DETAIL
533
300
REF - SUBSCRIBER ADDITIONAL
IDENTIFICATION
X12 Segment Name: Reference Information
X12 Purpose: To specify identifying information
X12 Syntax: 1. R0203
At least one of REF02 or REF03 is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 9

Usage: SITUATIONAL

71
06
30 Situational Rule: Required when the Information Source requires additional identifiers
necessary to identify the Subscriber for subsequent EDI transactions (see
Section 1.4.7);
OR
Required when the 270 request contained a REF segment with a Patient
Account Number in Loop 2100C/REF02 with REF01 equal EJ;
OR
Required when the 270 request contained a REF segment and the
information provided in that REF segment was used to locate the
individual in the information source’s system (See Section 1.4.7).
If not required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

672
300 TR3 Notes: 1. If the 270 request contained a REF segment with a Patient Account
Number in REF02 with REF01 equal EJ, then it must be returned in the
271 transaction using this segment if the patient is the Subscriber.
The Patient Account Number in the 271 transaction must be returned
exactly as submitted in the 270 transaction.

631
300 2. Use this segment to supply an identification number other than or in
addition to the Member Identification Number. The type of reference
number is determined by the qualifier in REF01. Only one occurrence
of each REF01 code value may be used in the 2100C loop.

632
300 3. Health Insurance Claim (HIC) Number or Medicaid Recipient
Identification Numbers are to be provided in the NM1 segment as a
Member Identification Number when it is the primary number an
information source knows a member by (such as for Medicare or
Medicaid). Do not use this segment for the Health Insurance Claim
(HIC) Number or Medicaid Recipient Identification Number unless they
are different from the Member Identification Number provided in the
NM1 segment.

492
300 TR3 Example: REF✽EJ✽660415~

APRIL 2008 253

005010X279 • 271 • 2100C • REF ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

Reference Reference Description Reference
REF ✽ Ident Qual
✽
Ident
✽ ✽
Identifier
~
M1 ID 2/3 X1 AN 1/50 X1 AN 1/80 O1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED REF01 128 Reference Identification Qualifier M1 ID 2/3

Code qualifying the Reference Identification

OD: 271B1_2100C_REF01__ReferenceIdentificationQualifier

300454 Use this code to specify or qualify the type of reference number
that is following in REF02, REF03, or both.

301055 Only one occurrence of each REF01 code value may be used in the
2100C loop.
CODE DEFINITION

18 Plan Number
1L Group or Policy Number
300614 Use this code only if it cannot be determined if the
number is a Group Number or a Policy number. Use
codes IG or 6P when they can be determined.
1W Member Identification Number
300704 Use only if Loop 2100C NM108 contains II, and is
prior to the mandated use of the HIPAA Unique
Patient Identifier.
3H Case Number
49 Family Unit Number
300943 Required when the Information Source is a
Pharmacy Benefit Manager (PBM) and the individual
has a suffix to their member ID number that is
required for use in the NCPDP Telecom Standard in
the Insurance Segment in field 303-C3 Person Code.
If not required by this implementation Guide, do not
send.

NOTE: For all other uses, the Family Unit Number

(suffix) is considered a part of the Member ID
number and is used to uniquely identify the
individual and must be returned at the end of the
Member ID number in 2100C NM109 or in 2100C
REF02 if REF01 is “1W”.
6P Group Number

254 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • REF
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ADDITIONAL IDENTIFICATION

CT Contract Number
300815 This code is to be used only to identify the
provider’s contract number of the provider identified
in the PRV segment of Loop 2100C. This code is
only to be used once the CMS National Provider
Identifier has been mandated for use, and must be
sent if required in the contract between the
Information Receiver identified in Loop 2100B and
the Information Source identified in Loop 2100A.
EA Medical Record Identification Number
EJ Patient Account Number
F6 Health Insurance Claim (HIC) Number
300809 See segment note 3.
GH Identification Card Serial Number
300633 Use this code when the Identification Card has a
number in addition to the Member Identification
Number or Identity Card Number. The Identification
Card Serial Number uniquely identifies the card
when multiple cards have been or will be issued to a
member (e.g., on a monthly basis, replacement
cards). This is particularly prevalent in the Medicaid
environment.
HJ Identity Card Number
300634 Use this code when the Identity Card Number is
different than the Member Identification Number.
This is particularly prevalent in the Medicaid
environment.
IF Issue Number
IG Insurance Policy Number
N6 Plan Network Identification Number
NQ Medicaid Recipient Identification Number
300833 See segment note 3.
Q4 Prior Identifier Number
300615 This code is to be used when a corrected or new
identification number is returned in NM109, the
originally submitted identification number is to be
returned in REF02. To be used in conjunction with
code “001" in INS03 and code ”25" in INS04.
SY Social Security Number
300658 The social security number may not be used for any
Federally administered programs such as Medicare.
Y4 Agency Claim Number
300944 This code is to only to be used when the information
source is a Property and Casualty payer. Use this
code to identify the Property and Casualty Claim
Number associated with the subscriber. This code is
not a HIPAA requirement as of this writing.

APRIL 2008 255

005010X279 • 271 • 2100C • REF ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3

REQUIRED REF02 127 Reference Identification X1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: R0203

OD: 271B1_2100C_REF02__SubscriberSupplementalIdentifier

IMPLEMENTATION NAME: Subscriber Supplemental Identifier

300453 Use this information for the reference number as qualified by the
preceding data element (REF01).

301056 If REF01 is “EJ”, the Patient Account Number from the 270
transaction must be returned exactly as submitted.
SITUATIONAL REF03 352 Description X1 AN 1/80
A free-form description to clarify the related data elements and their content
SYNTAX: R0203

300945 SITUATIONAL RULE: Required

when REF01 = “18", ”6P" or “N6" and a
name needs to be associated with the corresponding identifier. If
not required by this implementation guide, do not send.

OD: 271B1_2100C_REF03__PlanGrouporPlanNetworkName

IMPLEMENTATION NAME: Plan, Group or Plan Network Name

NOT USED REF04 C040 REFERENCE IDENTIFIER O1

256 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • N3
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ADDRESS
PARTY LOCATION SUBSCRIBER
005010X279 • 271 • 2100C • N3
ADDRESS
N3

SEGMENT DETAIL
534
300
N3 - SUBSCRIBER ADDRESS
X12 Segment Name: Party Location
X12 Purpose: To specify the location of the named party
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

73
06
30 Situational Rule: Required when the Subscriber is the patient or when the Information
Source requires this information to identify the Subscriber for subsequent
EDI transactions (see Section 1.4.7), but not required if a rejection
response is generated and this segment was not sent in the request. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

674
300 TR3 Notes: 1. Do not return address information from the 270 request.

575
300 2. Use this segment to identify address information for a subscriber.

493
300 TR3 Example: N3✽15197 BROADWAY AVENUE✽APT 215~

DIAGRAM

N301 166 N302 166

Address Address
N3 ✽
Information
✽
Information ~
M1 AN 1/55 O1 AN 1/55

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N301 166 Address Information M 1 AN 1/55

Address information

OD: 271B1_2100C_N301__SubscriberAddressLine

IMPLEMENTATION NAME: Subscriber Address Line

300455 Use this information for the first line of the address information.

APRIL 2008 257

005010X279 • 271 • 2100C • N3 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ADDRESS TECHNICAL REPORT • TYPE 3

SITUATIONAL N302 166 Address Information O 1 AN 1/55

Address information

300946 SITUATIONAL RULE: Requiredwhen the Information Source requires this

information to identify the Subscriber for subsequent EDI
transactions (see Section 1.4.7) unless a rejection response is
generated. If not required by this implementation guide, may be
provided at sender’s discretion but cannot be required by the
receiver.

OD: 271B1_2100C_N302__SubscriberAddressLine

IMPLEMENTATION NAME: Subscriber Address Line

300456 Use this information for the second line of the address information.

258 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • N4
TECHNICAL REPORT • TYPE 3 SUBSCRIBER CITY, STATE, ZIP CODE
GEOGRAPHIC LOCATION SUBSCRIBER
005010X279 • 271 • 2100C
CITY, STATE,• ZIP
N4 CODE
N4

SEGMENT DETAIL
535
300
N4 - SUBSCRIBER CITY, STATE, ZIP CODE
X12 Segment Name: Geographic Location
X12 Purpose: To specify the geographic place of the named party
X12 Syntax: 1. E0207
Only one of N402 or N407 may be present.
2. C0605
If N406 is present, then N405 is required.
3. C0704
If N407 is present, then N404 is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

73
06
30 Situational Rule: Required when the Subscriber is the patient or when the Information
Source requires this information to identify the Subscriber for subsequent
EDI transactions (see Section 1.4.7), but not required if a rejection
response is generated and this segment was not sent in the request. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

947
300 TR3 Notes: 1. Do not return address information from the 270 request.

948
300 2. Use this segment to identify address information for a subscriber.

920
300 TR3 Example: N4✽KANSAS CITY✽MO✽64108~

DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310
City State or Postal Country Location Location
N4 ✽ Name
✽
Prov Code
✽
Code
✽
Code
✽
Qualifier
✽
Identifier
O1 AN 2/30 X1 ID 2/2 O1 ID 3/15 X1 ID 2/3 X1 ID 1/2 O1 AN 1/30

N407 1715

✽ Country Sub ~
Code
X1 ID 1/3

APRIL 2008 259

005010X279 • 271 • 2100C • N4 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N401 19 City Name O 1 AN 2/30

Free-form text for city name
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.

OD: 271B1_2100C_N401__SubscriberCityName

IMPLEMENTATION NAME: Subscriber City Name

SITUATIONAL N402 156 State or Province Code X1 ID 2/2
Code (Standard State/Province) as defined by appropriate government agency
SYNTAX: E0207
COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

300921 SITUATIONAL RULE: Required

when the address is in the United States of
America, including its territories, or Canada. If not required by this
implementation guide, do not send.

OD: 271B1_2100C_N402__SubscriberStateCode

IMPLEMENTATION NAME: Subscriber State Code

CODE SOURCE 22: States and Provinces

SITUATIONAL N403 116 Postal Code O1 ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)

300922 SITUATIONAL RULE: Requiredwhen the address is in the United States of

America, including its territories, or Canada, or when a postal code
exists for the country in N404. If not required by this
implementation guide, do not send.

OD: 271B1_2100C_N403__SubscriberPostalZoneorZIPCode

IMPLEMENTATION NAME: Subscriber Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes
SITUATIONAL N404 26 Country Code X1 ID 2/3
Code identifying the country
SYNTAX: C0704

300923 SITUATIONAL RULE: Required

when the address is outside the United
States of America. If not required by this implementation guide, do
not send.

OD: 271B1_2100C_N404__SubscriberCountryCode

IMPLEMENTATION NAME: Subscriber Country Code

CODE SOURCE 5: Countries, Currencies and Funds

300924 Use the alpha-2 country codes from Part 1 of ISO 3166.

NOT USED N405 309 Location Qualifier X1 ID 1/2

NOT USED N406 310 Location Identifier O 1 AN 1/30

260 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • N4
TECHNICAL REPORT • TYPE 3 SUBSCRIBER CITY, STATE, ZIP CODE

SITUATIONAL N407 1715 Country Subdivision Code X1 ID 1/3

Code identifying the country subdivision
SYNTAX: E0207, C0704

300925 SITUATIONAL RULE: Required

when the address is not in the United
States of America, including its territories, or Canada, and the
country in N404 has administrative subdivisions such as but not
limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.

OD: 271B1_2100C_N407__SubscriberCountrySubdivisionCode

IMPLEMENTATION NAME: Subscriber Country Subdivision Code

CODE SOURCE 5: Countries, Currencies and Funds

300926 Use the country subdivision codes from Part 2 of ISO 3166.

APRIL 2008 261

 005010X279 • 271 • 2100C • AAA ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER REQUEST VALIDATION TECHNICAL REPORT • TYPE 3
REQUEST VALIDATION SUBSCRIBER
005010X279 • 271 • 2100CVALIDATION
REQUEST • AAA
AAA

SEGMENT DETAIL
591
300
AAA - SUBSCRIBER REQUEST VALIDATION
X12 Segment Name: Request Validation
X12 Purpose: To specify the validity of the request and indicate follow-up action authorized
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 9

Usage: SITUATIONAL

29
07
30 Situational Rule: Required when the request could not be processed at a system or
application level when specifically related to the data contained in the
original 270 transaction’s subscriber name loop (Loop 2100C) and to
indicate what action the originator of the request transaction should take.
If not required by this implementation guide, do not send.

730
300 TR3 Notes: 1. Use this segment to indicate problems in processing the transaction
specifically related to the data contained in the original 270
transaction’s subscriber name loop (Loop 2100C).

491
300 TR3 Example: AAA✽N✽✽72✽C~

DIAGRAM

AAA01 1073 AAA02 559 AAA03 901 AAA04 889

✽ Yes/No Cond ✽ Agency Reject Follow-up

AAA Resp Code Qual Code
✽
Reason Code
✽
Act Code ~
M1 ID 1/1 O1 ID 2/2 O1 ID 2/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED AAA01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: AAA01 designates whether the request is valid or invalid. Code “Y”
indicates that the code is valid; code “N” indicates that the code is invalid.

OD: 271B1_2100C_AAA01__ValidRequestIndicator

IMPLEMENTATION NAME: Valid Request Indicator

CODE DEFINITION

N No
300561 Use this code to indicate that the request or an
element in the request is not valid. The transaction
has been rejected as identified by the code in
AAA03.
Y Yes
300562 Use this code to indicate that the request is valid,
however the transaction has been rejected as
identified by the code in AAA03.
NOT USED AAA02 559 Agency Qualifier Code O1 ID 2/2

262 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • AAA
TECHNICAL REPORT • TYPE 3 SUBSCRIBER REQUEST VALIDATION

REQUIRED AAA03 901 Reject Reason Code O1 ID 2/2

Code assigned by issuer to identify reason for rejection

OD: 271B1_2100C_AAA03__RejectReasonCode

300438 Use this code for the reason why the transaction was unable to be
processed successfully. This may indicate problems with the
system, the application, or the data content.

300627 Use codes “43", ”45", “47", ”48", or “51" only in response to
information that is in or should be in the PRV segment in the
Subscriber Name loop (2100C).

301057 See section 1.4.8 Search Options for data content criteria for the
subscriber.
CODE DEFINITION

15 Required application data missing

35 Out of Network
300891 Use this code to indicate that the subscriber is not
in the Network of the provider identified in the 2100B
NM1 segment, or the 2100B/2100CPRV segment if
present in the 270 transaction.
42 Unable to Respond at Current Time
300576 Use this code in a batch environment where an
information source returns all requests from the 270
in the 271 and identifies “Unable to Respond at
Current Time” for each individual request
(subscriber or dependent) within the transaction
that they were unable to process for reasons other
than data content (such as their system is down or
timed out when generating a response).
43 Invalid/Missing Provider Identification
45 Invalid/Missing Provider Specialty
47 Invalid/Missing Provider State
48 Invalid/Missing Referring Provider Identification
Number
49 Provider is Not Primary Care Physician
51 Provider Not on File
52 Service Dates Not Within Provider Plan Enrollment
56 Inappropriate Date
57 Invalid/Missing Date(s) of Service
58 Invalid/Missing Date-of-Birth
300949 Code 58 may not be returned if the information
source has located an individual and the Birth Date
does not match; use code 71 instead.
60 Date of Birth Follows Date(s) of Service
61 Date of Death Precedes Date(s) of Service
62 Date of Service Not Within Allowable Inquiry Period
63 Date of Service in Future

APRIL 2008 263

005010X279 • 271 • 2100C • AAA ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER REQUEST VALIDATION TECHNICAL REPORT • TYPE 3

71 Patient Birth Date Does Not Match That for the

Patient on the Database
300950 Code 71 must be returned when the transaction was
rejected when the information source located an
individual based other information submitted, but
the Birth Date does not match.
72 Invalid/Missing Subscriber/Insured ID
300951 Required when the transaction was rejected when
the information source cannot find a match for the
Subscriber/Insured ID number submitted or if the ID
submitted was missing or formatted incorrectly.
73 Invalid/Missing Subscriber/Insured Name
301078 Required when the transaction was rejected when
the information source cannot find a match for the
Subscriber Name submitted or if the Subscriber
Name was missing.
74 Invalid/Missing Subscriber/Insured Gender Code
75 Subscriber/Insured Not Found
300953 Code 75 may not be returned if the information
receiver submitted all four pieces of the mandated
search option.
76 Duplicate Subscriber/Insured ID Number
78 Subscriber/Insured Not in Group/Plan Identified
REQUIRED AAA04 889 Follow-up Action Code O1 ID 1/1
Code identifying follow-up actions allowed

OD: 271B1_2100C_AAA04__FollowupActionCode

300437 Use this code to instruct the recipient of the 271 about what action
needs to be taken, if any, based on the validity code and the reject
reason code (if applicable).
CODE DEFINITION

C Please Correct and Resubmit

N Resubmission Not Allowed
R Resubmission Allowed
300577 Use only when AAA03 is “42".
S Do Not Resubmit; Inquiry Initiated to a Third Party
W Please Wait 30 Days and Resubmit
X Please Wait 10 Days and Resubmit
Y Do Not Resubmit; We Will Hold Your Request and
Respond Again Shortly
300577 Use only when AAA03 is “42".

264 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • PRV
TECHNICAL REPORT • TYPE 3 PROVIDER INFORMATION
PROVIDER INFORMATION • 271 • 2100C • PRV
005010X279INFORMATION
PROVIDER
PRV

SEGMENT DETAIL
818
300
PRV - PROVIDER INFORMATION
X12 Segment Name: Provider Information
X12 Purpose: To specify the identifying characteristics of a provider
X12 Syntax: 1. P0203
If either PRV02 or PRV03 is present, then the other is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

34
08
30 Situational Rule: Required when the 270 request contained a 2100C PRV segment and the
information contained in the PRV segment was used to determine the 271
response.;
OR
Required when needed either to identify a specific provider or to associate
a specialty type related to the service identified in the 2110C loops. This
PRV segment applies to all benefits in this 2100C loop unless overridden
by a PRV segment in the 2120C loop.
If not required by this implementation guide, do not send.

743
300 TR3 Notes: 1. If identifying a specific provider, use this segment to convey specific
information about a provider’s role in the eligibility/benefit being
inquired about when the provider is not the information receiver. For
example, if the information receiver is a hospital and a referring
provider must be identified, this is the segment where the referring
provider would be identified.

744
300 2. If identifying a specific provider, this segment contains reference
identification numbers, all of which may be used up until the time the
National Provider Identifier (NPI) is mandated for use. After the NPI is
mandated, only the code for National Provider Identifier may be used.

745
300 3. If identifying a type of specialty associated with the services identified
in loop 2110C, use code PXC in PRV02 and the appropriate code in
PRV03.

746
300 4. PRV02 qualifies PRV03.

835
300 5. If there is a PRV segment in 2100B, this PRV overrides it for this
occurrence of the 2100C loop.

050
301 TR3 Example: PRV✽RF✽PXC✽207Q00000X~

DIAGRAM

PRV01 1221 PRV02 128 PRV03 127 PRV04 156 PRV05 C035 PRV06 1223
Provider Reference Reference State or Provider Provider
PRV ✽
Code
✽
Ident Qual
✽
Ident
✽
Prov Code
✽
Spec. Inf.
✽
Org Code ~
M1 ID 1/3 X1 ID 2/3 X1 AN 1/50 O1 ID 2/2 O1 O1 ID 3/3

APRIL 2008 265

005010X279 • 271 • 2100C • PRV ASC X12N • INSURANCE SUBCOMMITTEE
PROVIDER INFORMATION TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PRV01 1221 Provider Code M1 ID 1/3

Code identifying the type of provider

OD: 271B1_2100C_PRV01__ProviderCode

CODE DEFINITION

AD Admitting
AT Attending
BI Billing
CO Consulting
CV Covering
H Hospital
HH Home Health Care
LA Laboratory
OT Other Physician
P1 Pharmacist
P2 Pharmacy
PC Primary Care Physician
PE Performing
R Rural Health Clinic
RF Referring
SK Skilled Nursing Facility
SU Supervising
SITUATIONAL PRV02 128 Reference Identification Qualifier X1 ID 2/3
Code qualifying the Reference Identification
SYNTAX: P0203

300954 SITUATIONAL RULE: Requiredwhen needed to identify a provider’s

specialty type. If not required by this implementation guide, do not
send.

OD: 271B1_2100C_PRV02__ReferenceIdentificationQualifier

CODE DEFINITION

PXC Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy

266 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • PRV
TECHNICAL REPORT • TYPE 3 PROVIDER INFORMATION

SITUATIONAL PRV03 127 Reference Identification X1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: P0203

300954 SITUATIONAL RULE: Requiredwhen needed to identify a provider’s

specialty type. If not required by this implementation guide, do not
send.

OD: 271B1_2100C_PRV03__ProviderIdentifier

IMPLEMENTATION NAME: Provider Identifier

300817 Use this number for the reference number as qualified by the
preceding data element (PRV02).
NOT USED PRV04 156 State or Province Code O1 ID 2/2
NOT USED PRV05 C035 PROVIDER SPECIALTY INFORMATION O1
NOT USED PRV06 1223 Provider Organization Code O1 ID 3/3

APRIL 2008 267

 005010X279 • 271 • 2100C • DMG ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER DEMOGRAPHIC INFORMATION TECHNICAL REPORT • TYPE 3
DEMOGRAPHIC INFORMATION SUBSCRIBER
005010X279 • 271 • 2100C • DMG
DEMOGRAPHIC INFORMATION
DMG

SEGMENT DETAIL
540
300
DMG - SUBSCRIBER DEMOGRAPHIC
INFORMATION
X12 Segment Name: Demographic Information
X12 Purpose: To supply demographic information
X12 Syntax: 1. P0102
If either DMG01 or DMG02 is present, then the other is required.
2. P1011
If either DMG10 or DMG11 is present, then the other is required.
3. C1105
If DMG11 is present, then DMG05 is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

75
06
30 Situational Rule: Required when the Subscriber is the patient or when the Information
Source requires this information to identify the Subscriber for subsequent
EDI transactions (see Section 1.4.7), but not required if a rejection
response is generated with a 2100C or 2110C AAA segment and this
segment was not sent in the request. If not required by this
implementation guide, may be provided at sender’s discretion but cannot
be required by the receiver.

466
300 TR3 Notes: 1. Use this segment to convey the birth date or gender demographic
information for the subscriber.

542
300 TR3 Example: DMG✽D8✽19430917✽M~

DIAGRAM

DMG01 1250 DMG02 1251 DMG03 1068 DMG04 1067 DMG05 C056 DMG06 1066
Date Time Date Time Gender Marital Comp Race Citizenship
DMG ✽
Format Qual
✽
Period
✽
Code
✽
Status Code
✽
or Ethn Inf
✽
Status Code
X1 ID 2/3 X1 AN 1/35 O1 ID 1/1 O1 ID 1/1 X 10 O1 ID 1/2

DMG07 26 DMG08 659 DMG09 380 DMG10 1270 DMG11 1271

Country Basis of Quantity Code List Industry
✽ ✽ ✽ ✽ ✽ ~
Code Verif Code Qual Code Code
O1 ID 2/3 O1 ID 1/2 O1 R 1/15 X1 ID 1/3 X1 AN 1/30

268 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • DMG
TECHNICAL REPORT • TYPE 3 SUBSCRIBER DEMOGRAPHIC INFORMATION

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

SITUATIONAL DMG01 1250 Date Time Period Format Qualifier X1 ID 2/3

Code indicating the date format, time format, or date and time format
SYNTAX: P0102

300955 SITUATIONAL RULE: Required

when Subscriber Birth Date is sent in
DMG02. If not required by this implementation guide, do not send.

OD: 271B1_2100C_DMG01__DateTimePeriodFormatQualifier

300467 Use this code to indicate the format of the date of birth that follows
in DMG02.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

SITUATIONAL DMG02 1251 Date Time Period X1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times
SYNTAX: P0102
SEMANTIC: DMG02 is the date of birth.

300675 SITUATIONAL RULE: Requiredwhen the Subscriber is the patient or when

the Information Source requires this information to identify the
Subscriber for subsequent EDI transactions (see Section 1.4.7), but
not required if a rejection response is generated with a 2100C or
2110C AAA segment and this segment was not sent in the request.
If not required by this implementation guide, may be provided at
sender’s discretion but cannot be required by the receiver.

OD: 271B1_2100C_DMG02__SubscriberBirthDate

IMPLEMENTATION NAME: Subscriber Birth Date

300956 Use this date for the date of birth of the subscriber.
SITUATIONAL DMG03 1068 Gender Code O1 ID 1/1
Code indicating the sex of the individual

300676 SITUATIONAL RULE: Requiredwhen the Information Source requires this

information to identify the Subscriber for subsequent EDI
transactions (see Section 1.4.7) unless a rejection response is
generated and this element was not valued in the request. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100C_DMG03__SubscriberGenderCode

IMPLEMENTATION NAME: Subscriber Gender Code

CODE DEFINITION

F Female
M Male
U Unknown
NOT USED DMG04 1067 Marital Status Code O1 ID 1/1
NOT USED DMG05 C056 COMPOSITE RACE OR ETHNICITY X
INFORMATION 10

APRIL 2008 269

005010X279 • 271 • 2100C • DMG ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER DEMOGRAPHIC INFORMATION TECHNICAL REPORT • TYPE 3

NOT USED DMG06 1066 Citizenship Status Code O1 ID 1/2

NOT USED DMG07 26 Country Code O1 ID 2/3
NOT USED DMG08 659 Basis of Verification Code O1 ID 1/2
NOT USED DMG09 380 Quantity O1 R 1/15
NOT USED DMG10 1270 Code List Qualifier Code X1 ID 1/3
NOT USED DMG11 1271 Industry Code X1 AN 1/30

270 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • INS
TECHNICAL REPORT • TYPE 3 SUBSCRIBER RELATIONSHIP
INSURED BENEFIT SUBSCRIBER
005010X279 • 271 • 2100C • INS
RELATIONSHIP
INS

SEGMENT DETAIL
592
300
INS - SUBSCRIBER RELATIONSHIP
X12 Segment Name: Insured Benefit
X12 Purpose: To provide benefit information on insured entities
X12 Syntax: 1. P1112
If either INS11 or INS12 is present, then the other is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

31
07
30 Situational Rule: Required when acknowledging a change in the identifying elements for
the subscriber from those submitted in the 270 or the Birth Sequence
Number submitted in INS17 of the 270 was used to locate the Subscriber.
If not required by this implementation guide, do not send.

656
300 TR3 Example: INS✽Y✽18✽001✽25~

DIAGRAM

INS01 1073 INS02 1069 INS03 875 INS04 1203 INS05 1216 INS06 C052

✽ Yes/No Cond ✽ Individual

✽ Maintenance ✽ Maintain Benefit
✽ Medicare
INS Resp Code Relat Code Type Code Reason Code
✽
Status Code Status Code
M1 ID 1/1 M1 ID 2/2 O1 ID 3/3 O1 ID 2/3 O1 ID 1/1 O1

INS07 1219 INS08 584 INS09 1220 INS10 1073 INS11 1250 INS12 1251

✽ COBRA Qual ✽ Employment ✽ Student

✽ Yes/No Cond ✽ Date Time ✽ Date Time
Event Code Status Code Status Code Resp Code Format Qual Period
O1 ID 1/2 O1 ID 2/2 O1 ID 1/1 O1 ID 1/1 X1 ID 2/3 X1 AN 1/35

INS13 1165 INS14 19 INS15 156 INS16 26 INS17 1470

Confident City State or Country Number
✽ ✽ ✽ ✽ ✽ ~
Code Name Prov Code Code
O1 ID 1/1 O1 AN 2/30 O1 ID 2/2 O1 ID 2/3 O1 N0 1/9

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED INS01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: INS01 indicates status of the insured. A “Y” value indicates the insured
is a subscriber: an “N” value indicates the insured is a dependent.

OD: 271B1_2100C_INS01__InsuredIndicator

IMPLEMENTATION NAME: Insured Indicator

CODE DEFINITION

Y Yes

APRIL 2008 271

005010X279 • 271 • 2100C • INS ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER RELATIONSHIP TECHNICAL REPORT • TYPE 3

REQUIRED INS02 1069 Individual Relationship Code M1 ID 2/2

Code indicating the relationship between two individuals or entities

OD: 271B1_2100C_INS02__IndividualRelationshipCode

CODE DEFINITION

18 Self
SITUATIONAL INS03 875 Maintenance Type Code O1 ID 3/3
Code identifying the specific type of item maintenance

300578 SITUATIONAL RULE: Required along with INS04 when acknowledging a

change in the identifying elements for the subscriber from those
submitted in the 270. If not required by this implementation guide,
do not send.

OD: 271B1_2100C_INS03__MaintenanceTypeCode

CODE DEFINITION

001 Change
SITUATIONAL INS04 1203 Maintenance Reason Code O1 ID 2/3
Code identifying the reason for the maintenance change

300579 SITUATIONAL RULE: Required along with INS03 when acknowledging a

change in the identifying elements for the subscriber from those
submitted in the 270. If not required by this implementation guide,
do not send.

OD: 271B1_2100C_INS04__MaintenanceReasonCode

CODE DEFINITION

25 Change in Identifying Data Elements

300580 Use this code to indicate that a change has been
made to the primary elements that identify a specific
person. Such elements are first name, last name,
date of birth, identification numbers, and address.
NOT USED INS05 1216 Benefit Status Code O1 ID 1/1
NOT USED INS06 C052 MEDICARE STATUS CODE O1
NOT USED INS07 1219 Consolidated Omnibus Budget Reconciliation O1 ID 1/2
Act (COBRA) Qualifying
NOT USED INS08 584 Employment Status Code O1 ID 2/2
NOT USED INS09 1220 Student Status Code O1 ID 1/1
NOT USED INS10 1073 Yes/No Condition or Response Code O1 ID 1/1
NOT USED INS11 1250 Date Time Period Format Qualifier X1 ID 2/3
NOT USED INS12 1251 Date Time Period X1 AN 1/35
NOT USED INS13 1165 Confidentiality Code O1 ID 1/1
NOT USED INS14 19 City Name O 1 AN 2/30
NOT USED INS15 156 State or Province Code O1 ID 2/2
NOT USED INS16 26 Country Code O1 ID 2/3

272 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • INS
TECHNICAL REPORT • TYPE 3 SUBSCRIBER RELATIONSHIP

SITUATIONAL INS17 1470 Number O1 N0 1/9

A generic number
SEMANTIC: INS17 is the number assigned to each family member born with the
same birth date. This number identifies birth sequence for multiple births allowing
proper tracking and response of benefits for each dependent (i.e., twins, triplets,
etc.).

300957 SITUATIONAL RULE: Required

when the Birth Sequence Number
submitted in the 270 was used to locate the Subscriber. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100C_INS17__BirthSequenceNumber

IMPLEMENTATION NAME: Birth Sequence Number

300635 Use to indicate the birth order in the event of multiple birth’s in
association with the birth date supplied in DMG02.

APRIL 2008 273

 005010X279 • 271 • 2100C • HI ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3
HEALTH CARE INFORMATION CODES 005010X279
SUBSCRIBER • 271 • 2100C
HEALTH • HIDIAGNOSIS CODE
CARE
HI

SEGMENT DETAIL
892
300
HI - SUBSCRIBER HEALTH CARE DIAGNOSIS
CODE
X12 Segment Name: Health Care Information Codes
X12 Purpose: To supply information related to the delivery of health care
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

94
08
30 Situational Rule: Required when an HI segment was received in the 270 and if the
information source uses the information in the determination of the
eligibility or benefit response for the subscriber. All information used from
the HI segment of the 270 used in the determination of the eligibility or
benefit response for the subscriber must be returned. If information was
provided in an HI segment of 270 but was not used in the determination of
the eligibility or benefits for the subscriber it must not be returned. The
information source must not use information in an HI segment of the 270
transaction in the determination of eligibility or benefits for the subscriber
if that information cannot be returned in the 271 response.
OR
Required when needed to identify limitations in the benefits identified in
the 2110C loops, such as if benefits are limited for a specific diagnosis
code if the information source can support this high level functionality. If
the information source cannot support this high level functionality, do not
send.

895
300 TR3 Notes: 1. Use the Diagnosis code pointers in 2110C EB14 to identify which
diagnosis code or codes in this HI segment relates to the information
provided in the EB segment.

896
300 2. Do not transmit the decimal points in the diagnosis codes. The
decimal point is assumed.

893
300 TR3 Example: HI✽BK:8901✽BF:87200✽BF:5559~

DIAGRAM

HI01 C022 HI02 C022 HI03 C022 HI04 C022 HI05 C022 HI06 C022

✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care
HI Code Info. Code Info. Code Info. Code Info. Code Info. Code Info.
M1 O1 O1 O1 O1 O1

HI07 C022 HI08 C022 HI09 C022 HI10 C022 HI11 C022 HI12 C022

✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ~
Code Info. Code Info. Code Info. Code Info. Code Info. Code Info.
O1 O1 O1 O1 O1 O1

274 APRIL 2008

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TECHNICAL REPORT • TYPE 3 SUBSCRIBER HEALTH CARE DIAGNOSIS CODE

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HI01 C022 HEALTH CARE CODE INFORMATION M1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

OD: 271B1_2100C_HI01_C022

300897 E codes are Not Used in HI01 except when defined by the claims
processor. E codes may be put in any other HI element using BF as
the qualifier.

300898 The diagnosis listed in this element is assumed to be the principal

diagnosis.
REQUIRED HI01 - 1 1270 Code List Qualifier Code M ID 1/3
Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100C_HI01_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABK International Classification of Diseases Clinical

Modification (ICD-10-CM) Principal Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BK International Classification of Diseases Clinical
Modification (ICD-9-CM) Principal Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI01 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100C_HI01_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI01 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI01 - 4 1251 Date Time Period X AN 1/35
NOT USED HI01 - 5 782 Monetary Amount O R 1/18
NOT USED HI01 - 6 380 Quantity O R 1/15
NOT USED HI01 - 7 799 Version Identifier O AN 1/30
NOT USED HI01 - 8 1271 Industry Code X AN 1/30
NOT USED HI01 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 275

005010X279 • 271 • 2100C • HI ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI02 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

301058 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data element has been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100C_HI02_C022

REQUIRED HI02 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100C_HI02_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI02 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100C_HI02_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI02 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI02 - 4 1251 Date Time Period X AN 1/35
NOT USED HI02 - 5 782 Monetary Amount O R 1/18
NOT USED HI02 - 6 380 Quantity O R 1/15
NOT USED HI02 - 7 799 Version Identifier O AN 1/30
NOT USED HI02 - 8 1271 Industry Code X AN 1/30
NOT USED HI02 - 9 1073 Yes/No Condition or Response Code X ID 1/1

276 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • HI
TECHNICAL REPORT • TYPE 3 SUBSCRIBER HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI03 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100C_HI03_C022

REQUIRED HI03 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100C_HI03_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI03 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100C_HI03_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI03 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI03 - 4 1251 Date Time Period X AN 1/35
NOT USED HI03 - 5 782 Monetary Amount O R 1/18
NOT USED HI03 - 6 380 Quantity O R 1/15
NOT USED HI03 - 7 799 Version Identifier O AN 1/30
NOT USED HI03 - 8 1271 Industry Code X AN 1/30
NOT USED HI03 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 277

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SUBSCRIBER HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI04 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100C_HI04_C022

REQUIRED HI04 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100C_HI04_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI04 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100C_HI04_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI04 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI04 - 4 1251 Date Time Period X AN 1/35
NOT USED HI04 - 5 782 Monetary Amount O R 1/18
NOT USED HI04 - 6 380 Quantity O R 1/15
NOT USED HI04 - 7 799 Version Identifier O AN 1/30
NOT USED HI04 - 8 1271 Industry Code X AN 1/30
NOT USED HI04 - 9 1073 Yes/No Condition or Response Code X ID 1/1

278 APRIL 2008

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TECHNICAL REPORT • TYPE 3 SUBSCRIBER HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI05 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100C_HI05_C022

REQUIRED HI05 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100C_HI05_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI05 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100C_HI05_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI05 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI05 - 4 1251 Date Time Period X AN 1/35
NOT USED HI05 - 5 782 Monetary Amount O R 1/18
NOT USED HI05 - 6 380 Quantity O R 1/15
NOT USED HI05 - 7 799 Version Identifier O AN 1/30
NOT USED HI05 - 8 1271 Industry Code X AN 1/30
NOT USED HI05 - 9 1073 Yes/No Condition or Response Code X ID 1/1

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SUBSCRIBER HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI06 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100C_HI06_C022

REQUIRED HI06 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100C_HI06_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI06 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100C_HI06_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI06 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI06 - 4 1251 Date Time Period X AN 1/35
NOT USED HI06 - 5 782 Monetary Amount O R 1/18
NOT USED HI06 - 6 380 Quantity O R 1/15
NOT USED HI06 - 7 799 Version Identifier O AN 1/30
NOT USED HI06 - 8 1271 Industry Code X AN 1/30
NOT USED HI06 - 9 1073 Yes/No Condition or Response Code X ID 1/1

280 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • HI
TECHNICAL REPORT • TYPE 3 SUBSCRIBER HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI07 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100C_HI07_C022

REQUIRED HI07 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100C_HI07_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI07 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100C_HI07_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI07 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI07 - 4 1251 Date Time Period X AN 1/35
NOT USED HI07 - 5 782 Monetary Amount O R 1/18
NOT USED HI07 - 6 380 Quantity O R 1/15
NOT USED HI07 - 7 799 Version Identifier O AN 1/30
NOT USED HI07 - 8 1271 Industry Code X AN 1/30
NOT USED HI07 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 281

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SUBSCRIBER HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI08 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100C_HI08_C022

REQUIRED HI08 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100C_HI08_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI08 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100C_HI08_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI08 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI08 - 4 1251 Date Time Period X AN 1/35
NOT USED HI08 - 5 782 Monetary Amount O R 1/18
NOT USED HI08 - 6 380 Quantity O R 1/15
NOT USED HI08 - 7 799 Version Identifier O AN 1/30
NOT USED HI08 - 8 1271 Industry Code X AN 1/30
NOT USED HI08 - 9 1073 Yes/No Condition or Response Code X ID 1/1
NOT USED HI09 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI10 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI11 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI12 C022 HEALTH CARE CODE INFORMATION O1

282 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • DTP
TECHNICAL REPORT • TYPE 3 SUBSCRIBER DATE
DATE OR TIME OR PERIOD SUBSCRIBER
005010X279 • 271
DATE• 2100C • DTP
DTP

SEGMENT DETAIL
593
300
DTP - SUBSCRIBER DATE
X12 Segment Name: Date or Time or Period
X12 Purpose: To specify any or all of a date, a time, or a time period
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 9

Usage: SITUATIONAL

59
09
30 Situational Rule: Required to identify the Plan (DTP01 = 291) or Plan Begin (DTP01 = 346)
date when the individual has active coverage unless multiple plans apply
to the individual or multiple plan periods apply, which must then be
returned in the 2110C DTP (See Section 1.4.7);
OR
Required when needed to identify other relevant dates that apply to the
Subscriber.
If not required by this implementation guide, do not send.

461
300 TR3 Notes: 1. The dates represented may be in the past, the current date, or a future
date. The dates may also be a single date or a span of dates. Which
date(s) to use is determined by the format qualifier in DTP02.

958
300 2. Dates supplied in the 2100C DTP apply to the Subscriber and all
2110C loops unless overridden by an occurrence of a 2110C DTP with
the same value in DTP01.

494
300 TR3 Example: DTP✽346✽D8✽19950818~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251

Date/Time
✽ Date Time ✽ Date Time
DTP ✽ Qualifier Format Qual Period ~
M1 ID 3/3 M1 ID 2/3 M1 AN 1/35

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED DTP01 374 Date/Time Qualifier M1 ID 3/3

Code specifying type of date or time, or both date and time

OD: 271B1_2100C_DTP01__DateTimeQualifier

IMPLEMENTATION NAME: Date Time Qualifier

CODE DEFINITION

096 Discharge
102 Issue
152 Effective Date of Change
291 Plan

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SUBSCRIBER DATE TECHNICAL REPORT • TYPE 3

307 Eligibility
318 Added
301059 Information Sources are encouraged to return
Added date in the case of retroactive eligibility.
340 Consolidated Omnibus Budget Reconciliation Act
(COBRA) Begin
341 Consolidated Omnibus Budget Reconciliation Act
(COBRA) End
342 Premium Paid to Date Begin
343 Premium Paid to Date End
346 Plan Begin
347 Plan End
356 Eligibility Begin
357 Eligibility End
382 Enrollment
435 Admission
442 Date of Death
458 Certification
472 Service
539 Policy Effective
540 Policy Expiration
636 Date of Last Update
771 Status
REQUIRED DTP02 1250 Date Time Period Format Qualifier M1 ID 2/3
Code indicating the date format, time format, or date and time format
SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

OD: 271B1_2100C_DTP02__DateTimePeriodFormatQualifier

300463 Use this code to specify the format of the date(s)/time(s) that follow
in the next data element.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

RD8 Range of Dates Expressed in Format CCYYMMDD-
CCYYMMDD
REQUIRED DTP03 1251 Date Time Period M 1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times

OD: 271B1_2100C_DTP03__DateTimePeriod

300462 Use this date for the date(s) as qualified by the preceding data
elements.

284 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • MPI
TECHNICAL REPORT • TYPE 3 SUBSCRIBER MILITARY PERSONNEL INFORMATION
MILITARY PERSONNEL INFORMATION 005010X279
SUBSCRIBER • 271 • 2100C
MILITARY • MPI
PERSONNEL INFORMATION
MPI

SEGMENT DETAIL
960
300
MPI - SUBSCRIBER MILITARY PERSONNEL
INFORMATION
X12 Segment Name: Military Personnel Information
X12 Purpose: To report military service data
X12 Syntax: 1. P0607
If either MPI06 or MPI07 is present, then the other is required.
Loop: 2100C — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

61
09
30 Situational Rule: Required when this transaction is processed by DOD or
CHAMPUS/TRICARE and when necessary to convey the Subscriber’s
military service data If not required by this implementation guide, do not
send.

086
301 TR3 Example: MPI✽C✽AO✽A✽✽L3~
Current Active Military - Overseas Air Force Lieutenant Colonel

DIAGRAM

MPI01 1201 MPI02 584 MPI03 1595 MPI04 352 MPI05 1596 MPI06 1250

✽ Information ✽ Employment ✽ Gov. Serv. Description Mil. Serv.

✽ Date Time
MPI Status Code Status Code Affil. Code
✽ ✽
Rank Code Format Qual
M1 ID 1/1 M1 ID 2/2 M1 ID 1/1 O1 AN 1/80 O1 ID 2/2 X1 ID 2/3

MPI07 1251
Date Time
✽ ~
Period
X1 AN 1/35

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED MPI01 1201 Information Status Code M1 ID 1/1

A code to indicate the status of information

OD: 271B1_2100C_MPI01__InformationStatusCode

CODE DEFINITION

A Partial
C Current
L Latest
O Oldest
P Prior
S Second Most Current
T Third Most Current

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SUBSCRIBER MILITARY PERSONNEL INFORMATION TECHNICAL REPORT • TYPE 3

REQUIRED MPI02 584 Employment Status Code M1 ID 2/2

Code showing the general employment status of an employee/claimant

OD: 271B1_2100C_MPI02__EmploymentStatusCode

CODE DEFINITION

AE Active Reserve
AO Active Military - Overseas
AS Academy Student
AT Presidential Appointee
AU Active Military - USA
CC Contractor
DD Dishonorably Discharged
HD Honorably Discharged
IR Inactive Reserves
LX Leave of Absence: Military
PE Plan to Enlist
RE Recommissioned
RM Retired Military - Overseas
RR Retired Without Recall
RU Retired Military - USA
REQUIRED MPI03 1595 Government Service Affiliation Code M1 ID 1/1
Code specifying the government service affiliation

OD: 271B1_2100C_MPI03__GovernmentServiceAffiliationCode

CODE DEFINITION

A Air Force
B Air Force Reserves
C Army
D Army Reserves
E Coast Guard
F Marine Corps
G Marine Corps Reserves
H National Guard
I Navy
J Navy Reserves
K Other
L Peace Corp
M Regular Armed Forces
N Reserves
O U.S. Public Health Service
Q Foreign Military
R American Red Cross
S Department of Defense
U United Services Organization
W Military Sealift Command

286 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100C • MPI
TECHNICAL REPORT • TYPE 3 SUBSCRIBER MILITARY PERSONNEL INFORMATION

SITUATIONAL MPI04 352 Description O 1 AN 1/80

A free-form description to clarify the related data elements and their content
SEMANTIC: MPI04 is the actual response to further identify the exact military unit.

300962 SITUATIONAL RULE: Required when needed to further identify the exact
military unit. If not required by this implementation guide, do not
send.

OD: 271B1_2100C_MPI04__Description

SITUATIONAL MPI05 1596 Military Service Rank Code O1 ID 2/2

Code specifying the military service rank

300963 SITUATIONAL RULE: Required

when needed to indicate the current or
most recent military service rank. If not required by this
implementation guide, do not send.

OD: 271B1_2100C_MPI05__MilitaryServiceRankCode

CODE DEFINITION

A1 Admiral
A2 Airman
A3 Airman First Class
B1 Basic Airman
B2 Brigadier General
C1 Captain
C2 Chief Master Sergeant
C3 Chief Petty Officer
C4 Chief Warrant
C5 Colonel
C6 Commander
C7 Commodore
C8 Corporal
C9 Corporal Specialist 4
E1 Ensign
F1 First Lieutenant
F2 First Sergeant
F3 First Sergeant-Master Sergeant
F4 Fleet Admiral
G1 General
G4 Gunnery Sergeant
L1 Lance Corporal
L2 Lieutenant
L3 Lieutenant Colonel
L4 Lieutenant Commander
L5 Lieutenant General
L6 Lieutenant Junior Grade
M1 Major
M2 Major General
M3 Master Chief Petty Officer

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M4 Master Gunnery Sergeant Major

M5 Master Sergeant
M6 Master Sergeant Specialist 8
P1 Petty Officer First Class
P2 Petty Officer Second Class
P3 Petty Officer Third Class
P4 Private
P5 Private First Class
R1 Rear Admiral
R2 Recruit
S1 Seaman
S2 Seaman Apprentice
S3 Seaman Recruit
S4 Second Lieutenant
S5 Senior Chief Petty Officer
S6 Senior Master Sergeant
S7 Sergeant
S8 Sergeant First Class Specialist 7
S9 Sergeant Major Specialist 9
SA Sergeant Specialist 5
SB Staff Sergeant
SC Staff Sergeant Specialist 6
T1 Technical Sergeant
V1 Vice Admiral
W1 Warrant Officer
SITUATIONAL MPI06 1250 Date Time Period Format Qualifier X1 ID 2/3
Code indicating the date format, time format, or date and time format
SYNTAX: P0607

300964 SITUATIONAL RULE: Required

when needed to indicate the beginning
date or date span of military service. If not required by this
implementation guide, do not send.

OD: 271B1_2100C_MPI06__DateTimePeriodFormatQualifier

CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

RD8 Range of Dates Expressed in Format CCYYMMDD-
CCYYMMDD
SITUATIONAL MPI07 1251 Date Time Period X1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times
SYNTAX: P0607
SEMANTIC: MPI07 indicates the date span of military service.

300964 SITUATIONAL RULE: Required

when needed to indicate the beginning
date or date span of military service. If not required by this
implementation guide, do not send.

OD: 271B1_2100C_MPI07__DateTimePeriod

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TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION
ELIGIBILITY OR BENEFIT INFORMATION 005010X279
SUBSCRIBER • 271 • 2110C OR
ELIGIBILITY • EB
BENEFIT INFORMATION
EB

SEGMENT DETAIL
594
300
EB - SUBSCRIBER ELIGIBILITY OR BENEFIT
INFORMATION
X12 Segment Name: Eligibility or Benefit Information
X12 Purpose: To supply eligibility or benefit information
X12 Syntax: 1. P0910
If either EB09 or EB10 is present, then the other is required.
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION Loop
Repeat: >1

Segment Repeat: 1

Usage: SITUATIONAL

78
06
30 Situational Rule: Required when the subscriber is the person whose eligibility or benefits
are being described and the transaction is not rejected (see Section
1.4.10) or if the transaction needs to be rejected in this loop. If not
required by this implementation guide, do not send.

819
300 TR3 Notes: 1. See Section 1.4.7 Implementation-Compliant Use of the 270/271
Transaction Set for information about what information must be
returned if the subscriber is the person whose eligibility or benefits
are being sent.

854
300 2. Either EB03 or EB13 may be used in the same EB segment, not both.

820
300 3. EB03 is a repeating data element that may be repeated up to 99 times.
If all of the information that will be used in the 2110C loop is the same
with the exception of the Service Type Code used in EB03, it is more
efficient to use the repetition function of EB03 to send each of the
Service Type Codes needed. If an Information Source supports
responses with multiple Service Type Codes, the repetition use of
EB03 must be supported if all other elements in the 2110C loop are
identical.

679
300 4. A limit to the number of repeats of EB loops has not been established.
In a batch environment there is no practical reason to limit the number
of EB loop repeats. In a real time environment, consideration should
be given to how many EB loops are generated given the amount of
time it takes to format the response and the amount of time it will take
to transmit that response. Since these limitations will vary by
information source, it would be completely arbitrary for the
developers to set a limit. It is not the intent of the developers to limit
the amount of information that is returned in a response, rather to
alert information sources to consider the potential delays if the
response contains too much information to be formatted and
transmitted in real time.

468
300 5. Use this segment to begin the eligibility/benefit information looping
structure. The EB segment is used to convey the specific eligibility or
benefit information for the entity identified.

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495
300 TR3 Example: EB✽1✽FAM✽96✽GP~
Active Coverage for subscriber and family, for Professional (Physician)
services, and coverage is through a Group Policy

509
300 TR3 Example: EB✽B✽✽68✽✽✽27✽10~
Co-payment for Well Baby Care is $10 per visit

510
300 TR3 Example: EB✽C✽FAM✽✽✽✽23✽600~
Deductible for the family is $600 per calendar year

511
300 TR3 Example: EB✽L~
Primary Care Provider (information about the Primary Care Provider will
be located in the 2120 loop)

677
300 TR3 Example: EB✽A✽✽A6✽✽✽✽✽.50~
Co-Insurance is 50 percent for Psychotherapy

821
300 TR3 Example: EB✽B✽✽98^34^44^81^A0^A3✽✽✽✽10✽✽VS✽1~
Co-payment for Professional (Physician) Visit - Office, Chiropractic Office
Visits, Home Health Visits, Routine Physical, Professional (Physician)
Visit - Outpatient, Professional (Physician) Visit - Home, is $10 for one visit

DIAGRAM

EB01 1390 EB02 1207 EB03 1365 EB04 1336 EB05 1204 EB06 615
Eligibility Coverage Service Insurance Plan Cvrg
✽ Time Period
EB ✽ Benefit Inf
✽
Level Code
✽
Type Code
✽
Type Code
✽
Description Qualifier
M1 ID 1/2 O1 ID 3/3 O 99 ID 1/2 O1 ID 1/3 O1 AN 1/50 O1 ID 1/2

EB07 782 EB08 954 EB09 673 EB10 380 EB11 1073 EB12 1073
Monetary Percent Quantity Quantity
✽ ✽ ✽ ✽ ✽ Yes/No Cond ✽ Yes/No Cond
Amount Qualifier Resp Code Resp Code
O1 R 1/18 O1 R 1/10 X1 ID 2/2 X1 R 1/15 O1 ID 1/1 O1 ID 1/1

EB13 C003 EB14 C004

Comp. Med.
✽ ✽ Comp. Diag. ~
Proced. ID Code Point.
O1 O1

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ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED EB01 1390 Eligibility or Benefit Information Code M1 ID 1/2

Code identifying eligibility or benefit information
SEMANTIC: EB01 qualifies EB06 through EB10.

OD: 271B1_2110C_EB01__EligibilityorBenefitInformation

IMPLEMENTATION NAME: Eligibility or Benefit Information

300469 Use this code to identify the eligibility or benefit information. This
may be the eligibility status of the individual or the benefit related
category that is being further described in the following data
elements. This data element also qualifies the data in elements
EB06 through EB10.

300845 If codes A, B, C, G, J or Y are used, it is required that the patient’s

portion of responsibility is reflected in either EB07 or EB08. See
Section 1.4.9 Patient Responsibility for detailed information and
definitions.
CODE DEFINITION

1 Active Coverage
2 Active - Full Risk Capitation
3 Active - Services Capitated
4 Active - Services Capitated to Primary Care
Physician
5 Active - Pending Investigation
6 Inactive
7 Inactive - Pending Eligibility Update
8 Inactive - Pending Investigation
A Co-Insurance
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
B Co-Payment
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
C Deductible
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
CB Coverage Basis
D Benefit Description
E Exclusions
F Limitations
G Out of Pocket (Stop Loss)
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
H Unlimited
I Non-Covered

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J Cost Containment
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
K Reserve
L Primary Care Provider
M Pre-existing Condition
MC Managed Care Coordinator
N Services Restricted to Following Provider
O Not Deemed a Medical Necessity
P Benefit Disclaimer
300680 Not recommended. See section 1.4.11 Disclaimers
Within the Transaction.
Q Second Surgical Opinion Required
R Other or Additional Payor
S Prior Year(s) History
T Card(s) Reported Lost/Stolen
300822 Code “T” is typically used by Medicaids to indicate
to a provider that the person who has presented the
ID card is using a stolen ID card.
U Contact Following Entity for Eligibility or Benefit
Information
V Cannot Process
W Other Source of Data
X Health Care Facility
Y Spend Down
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
SITUATIONAL EB02 1207 Coverage Level Code O1 ID 3/3
Code indicating the level of coverage being provided for this insured

300475 SITUATIONAL RULE: Requiredwhen needed to identify the types of

individuals associated with the eligibility or benefits being
identified in the 2110C loop. If not required by this implementation
guide, do not send.

OD: 271B1_2110C_EB02__BenefitCoverageLevelCode

IMPLEMENTATION NAME: Benefit Coverage Level Code

300965 This element is used in conjunction with EB01 codes (e.g. Active
Family Coverage, Deductible Individual, etc.). This element can be
used to identify types of individual’s within the Subscriber’s family
that eligibility or benefits extends to (unless EB01 = E - Exclusions).
CODE DEFINITION

CHD Children Only

DEP Dependents Only
ECH Employee and Children
EMP Employee Only
ESP Employee and Spouse

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FAM Family
IND Individual
SPC Spouse and Children
SPO Spouse Only
SITUATIONAL EB03 1365 Service Type Code O ID 1/2
99
Code identifying the classification of service
SEMANTIC: Position of data in the repeating data element conveys no significance.

300966 SITUATIONAL RULE: Required when the subscriber is the patient and has
been found in the Information Source’s system to identify Active or
Inactive Health Benefit Plan Coverage (See Section 1.4.7);
OR
Required when one of the Service Type Codes identified in Section
1.4.7 must be returned;
OR
Required when responding to a corresponding Service Type code
used from the 270 transaction;
OR
Required when the eligibility or benefits being identified in the
2110C loop need to be associated with a specific Service Type
Code.
If not required by this implementation guide or if EB13 is used, do
not send.

OD: 271B1_2110C_EB03__ServiceTypeCode

300900 See Section 1.4.7 Implementation-Compliant Use of the 270/271

Transaction Set for information about what service type codes
must be returned.

300836 EB03 is a repeating data element that may be repeated up to 99

times. If all of the information that will be used in the 2110C loop is
the same with the exception of the Service Type Code used in
EB03, it is more efficient to use the repetition function of EB03 to
send each of the Service Type Codes needed. If an Information
Source supports responses with multiple Service Type Codes, the
repetition use of EB03 must be supported if all other elements in
the 2110C loop are identical.

300855 Not used if EB13 is present.

CODE DEFINITION

1 Medical Care
2 Surgical
3 Consultation
4 Diagnostic X-Ray
5 Diagnostic Lab
6 Radiation Therapy
7 Anesthesia
8 Surgical Assistance
9 Other Medical
10 Blood Charges
11 Used Durable Medical Equipment

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12 Durable Medical Equipment Purchase

13 Ambulatory Service Center Facility
14 Renal Supplies in the Home
15 Alternate Method Dialysis
16 Chronic Renal Disease (CRD) Equipment
17 Pre-Admission Testing
18 Durable Medical Equipment Rental
19 Pneumonia Vaccine
20 Second Surgical Opinion
21 Third Surgical Opinion
22 Social Work
23 Diagnostic Dental
24 Periodontics
25 Restorative
26 Endodontics
27 Maxillofacial Prosthetics
28 Adjunctive Dental Services
30 Health Benefit Plan Coverage
301060 See Section 1.4.7.1
32 Plan Waiting Period
33 Chiropractic
34 Chiropractic Office Visits
35 Dental Care
36 Dental Crowns
37 Dental Accident
38 Orthodontics
39 Prosthodontics
40 Oral Surgery
41 Routine (Preventive) Dental
42 Home Health Care
43 Home Health Prescriptions
44 Home Health Visits
45 Hospice
46 Respite Care
47 Hospital
48 Hospital - Inpatient
49 Hospital - Room and Board
50 Hospital - Outpatient
51 Hospital - Emergency Accident
52 Hospital - Emergency Medical
53 Hospital - Ambulatory Surgical
54 Long Term Care
55 Major Medical
56 Medically Related Transportation

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57 Air Transportation
58 Cabulance
59 Licensed Ambulance
60 General Benefits
61 In-vitro Fertilization
62 MRI/CAT Scan
63 Donor Procedures
64 Acupuncture
65 Newborn Care
66 Pathology
67 Smoking Cessation
68 Well Baby Care
69 Maternity
70 Transplants
71 Audiology Exam
72 Inhalation Therapy
73 Diagnostic Medical
74 Private Duty Nursing
75 Prosthetic Device
76 Dialysis
77 Otological Exam
78 Chemotherapy
79 Allergy Testing
80 Immunizations
81 Routine Physical
82 Family Planning
83 Infertility
84 Abortion
85 AIDS
86 Emergency Services
87 Cancer
88 Pharmacy
89 Free Standing Prescription Drug
90 Mail Order Prescription Drug
91 Brand Name Prescription Drug
92 Generic Prescription Drug
93 Podiatry
94 Podiatry - Office Visits
95 Podiatry - Nursing Home Visits
96 Professional (Physician)
97 Anesthesiologist
98 Professional (Physician) Visit - Office
99 Professional (Physician) Visit - Inpatient
A0 Professional (Physician) Visit - Outpatient

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SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION TECHNICAL REPORT • TYPE 3

A1 Professional (Physician) Visit - Nursing Home

A2 Professional (Physician) Visit - Skilled Nursing
Facility
A3 Professional (Physician) Visit - Home
A4 Psychiatric
A5 Psychiatric - Room and Board
A6 Psychotherapy
A7 Psychiatric - Inpatient
A8 Psychiatric - Outpatient
A9 Rehabilitation
AA Rehabilitation - Room and Board
AB Rehabilitation - Inpatient
AC Rehabilitation - Outpatient
AD Occupational Therapy
AE Physical Medicine
AF Speech Therapy
AG Skilled Nursing Care
AH Skilled Nursing Care - Room and Board
AI Substance Abuse
AJ Alcoholism
AK Drug Addiction
AL Vision (Optometry)
AM Frames
AN Routine Exam
300856 Use for Routine Vision Exam only.
AO Lenses
AQ Nonmedically Necessary Physical
AR Experimental Drug Therapy
B1 Burn Care
B2 Brand Name Prescription Drug - Formulary
B3 Brand Name Prescription Drug - Non-Formulary
BA Independent Medical Evaluation
BB Partial Hospitalization (Psychiatric)
BC Day Care (Psychiatric)
BD Cognitive Therapy
BE Massage Therapy
BF Pulmonary Rehabilitation
BG Cardiac Rehabilitation
BH Pediatric
BI Nursery
BJ Skin
BK Orthopedic
BL Cardiac
BM Lymphatic

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TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

BN Gastrointestinal
BP Endocrine
BQ Neurology
BR Eye
BS Invasive Procedures
BT Gynecological
BU Obstetrical
BV Obstetrical/Gynecological
BW Mail Order Prescription Drug: Brand Name
BX Mail Order Prescription Drug: Generic
BY Physician Visit - Office: Sick
BZ Physician Visit - Office: Well
C1 Coronary Care
CA Private Duty Nursing - Inpatient
CB Private Duty Nursing - Home
CC Surgical Benefits - Professional (Physician)
CD Surgical Benefits - Facility
CE Mental Health Provider - Inpatient
CF Mental Health Provider - Outpatient
CG Mental Health Facility - Inpatient
CH Mental Health Facility - Outpatient
CI Substance Abuse Facility - Inpatient
CJ Substance Abuse Facility - Outpatient
CK Screening X-ray
CL Screening laboratory
CM Mammogram, High Risk Patient
CN Mammogram, Low Risk Patient
CO Flu Vaccination
CP Eyewear and Eyewear Accessories
CQ Case Management
DG Dermatology
DM Durable Medical Equipment
DS Diabetic Supplies
GF Generic Prescription Drug - Formulary
GN Generic Prescription Drug - Non-Formulary
GY Allergy
IC Intensive Care
MH Mental Health
NI Neonatal Intensive Care
ON Oncology
PT Physical Therapy
PU Pulmonary
RN Renal
RT Residential Psychiatric Treatment

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SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION TECHNICAL REPORT • TYPE 3

TC Transitional Care
TN Transitional Nursery Care
UC Urgent Care
SITUATIONAL EB04 1336 Insurance Type Code O1 ID 1/3
Code identifying the type of insurance policy within a specific insurance program

300967 SITUATIONAL RULE: Required when the Information Source requires the
Subscriber’s Insurance Type Code for subsequent EDI transactions
(see Section 1.4.7). If not required by this implementation guide,
may be provided at sender’s discretion but cannot be required by
the receiver.

OD: 271B1_2110C_EB04__InsuranceTypeCode

CODE DEFINITION

12 Medicare Secondary Working Aged Beneficiary or

Spouse with Employer Group Health Plan
13 Medicare Secondary End-Stage Renal Disease
Beneficiary in the Mandated Coordination Period
with an Employer’s Group Health Plan
14 Medicare Secondary, No-fault Insurance including
Auto is Primary
15 Medicare Secondary Worker’s Compensation
16 Medicare Secondary Public Health Service (PHS)or
Other Federal Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veteran’s Administration
43 Medicare Secondary Disabled Beneficiary Under
Age 65 with Large Group Health Plan (LGHP)
47 Medicare Secondary, Other Liability Insurance is
Primary
AP Auto Insurance Policy
C1 Commercial
CO Consolidated Omnibus Budget Reconciliation Act
(COBRA)
CP Medicare Conditionally Primary
D Disability
DB Disability Benefits
EP Exclusive Provider Organization
FF Family or Friends
GP Group Policy
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) - Medicare
Risk
HS Special Low Income Medicare Beneficiary
IN Indemnity
IP Individual Policy
LC Long Term Care
LD Long Term Policy

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LI Life Insurance
LT Litigation
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
OT Other
301061 When this code is returned by Medicare or a
Medicare Part D administrator, this code indicates a
type of insurance of Medicare Part D.
PE Property Insurance - Personal
PL Personal
PP Personal Payment (Cash - No Insurance)
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare Beneficiary
RP Property Insurance - Real
SP Supplemental Policy
TF Tax Equity Fiscal Responsibility Act (TEFRA)
WC Workers Compensation
WU Wrap Up Policy
SITUATIONAL EB05 1204 Plan Coverage Description O 1 AN 1/50
A description or number that identifies the plan or coverage

300968 SITUATIONAL RULE: Required when a specific Plan Name exists for the
plan which the individual has coverage in conjunction with the
2110C loop with EB01 Status = 1, 2, 3, 4, 5, 6, 7 or 8 and EB03
Service Type Code = 30 (See Section 1.4.7). If not required by this
implementation guide, may be provided at sender’s discretion but
cannot be required by the receiver.

OD: 271B1_2110C_EB05__PlanCoverageDescription

300847 This element is to be used only to convey the specific product

name or special program name for an insurance plan. For example,
if a plan has a brand name, such as “Gold 1-2-3", the name may be
placed in this element. This element must not be used to give
benefit details of a plan.

SITUATIONAL EB06 615 Time Period Qualifier O1 ID 1/2

Code defining periods

300732 SITUATIONAL RULE: Requiredwhen the availability of the eligibility or

benefits being identified in the 2110C loop need to be qualified by a
time period. If not required by this implementation guide, do not
send.

OD: 271B1_2110C_EB06__TimePeriodQualifier

CODE DEFINITION

6 Hour

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7 Day
13 24 Hours
21 Years
22 Service Year
23 Calendar Year
24 Year to Date
25 Contract
26 Episode
27 Visit
28 Outlier
29 Remaining
30 Exceeded
31 Not Exceeded
32 Lifetime
33 Lifetime Remaining
34 Month
35 Week
36 Admission
SITUATIONAL EB07 782 Monetary Amount O1 R 1/18
Monetary amount

300852 SITUATIONAL RULE: Required when EB01 = B, C, G, J or Y. Do not use if

EB01 = A. May be used at the sender’s discretion for other EB01
values. May not be a negative number.

OD: 271B1_2110C_EB07__BenefitAmount

IMPLEMENTATION NAME: Benefit Amount

300473 Use this monetary amount as qualified by EB01.

300969 When EB01 = B, C, G, J or Y, the amount represents the Patient’s

portion of responsibility. See Section 1.4.9 Patient Responsibility.

300648 Use if eligibility or benefit must be qualified by a monetary amount;

e.g., deductible, co-payment.

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SITUATIONAL EB08 954 Percentage as Decimal O1 R 1/10

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

300853 SITUATIONAL RULE: Required

when EB01 = A. Do not use if EB01 = B, C,
G, J or Y. May be used at the sender’s discretion for other EB01
values. May not be a negative number.

OD: 271B1_2110C_EB08__BenefitPercent

IMPLEMENTATION NAME: Benefit Percent

300474 Use this percentage rate as qualified by EB01.

300970 When EB01 = A, the amount represents the Patient’s portion of

responsibility. See Section 1.4.9 Patient Responsibility.

300649 Use if eligibility or benefit must be qualified by a percentage; e.g.,

co-insurance.

SITUATIONAL EB09 673 Quantity Qualifier X1 ID 2/2

Code specifying the type of quantity
SYNTAX: P0910

300971 SITUATIONAL RULE: Required when needed to further qualify the

eligibility or benefits being identified in the 2110C loop by quantity.
If not required by this implementation guide, do not send.

OD: 271B1_2110C_EB09__QuantityQualifier

300472 Use this code to identify the type of units that are being conveyed
in the following data element (EB10).
CODE DEFINITION

8H Minimum
99 Quantity Used
CA Covered - Actual
CE Covered - Estimated
D3 Number of Co-insurance Days
DB Deductible Blood Units
DY Days
HS Hours
LA Life-time Reserve - Actual
LE Life-time Reserve - Estimated
M2 Maximum
MN Month
P6 Number of Services or Procedures
QA Quantity Approved
S7 Age, High Value
300616 Use this code when a benefit is based on a
maximum age for the patient.
S8 Age, Low Value
300617 Use this code when a benefit is based on a minimum
age for the patient.

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VS Visits
YY Years
SITUATIONAL EB10 380 Quantity X1 R 1/15
Numeric value of quantity
SYNTAX: P0910

301034 SITUATIONAL RULE: Required when needed to further qualify the

eligibility or benefits being identified in the 2110C loop by quantity.
If not required by this implementation guide, do not send.

OD: 271B1_2110C_EB10__BenefitQuantity

IMPLEMENTATION NAME: Benefit Quantity

300471 Use this number for the quantity value as qualified by the
preceding data element (EB09).

SITUATIONAL EB11 1073 Yes/No Condition or Response Code O1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: 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.

300972 SITUATIONAL RULE: Required when needed to indicate if authorization or

certification is required for the eligibility or benefits being identified
in the 2110C loop. If not required by this implementation guide, do
not send.

OD: 271B1_2110C_EB11__AuthorizationorCertificationIndicator

IMPLEMENTATION NAME: Authorization or Certification Indicator

300823 Use code “U” - Unknown, In the event that a payer typically
responds Yes or No for some benefits, but the inquired benefit
requirements are not accessible or the rules are more complex than
can be determined using the data sent in the 270.
CODE DEFINITION

N No
U Unknown
Y Yes

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ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • EB
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

SITUATIONAL EB12 1073 Yes/No Condition or Response Code O1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: 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.

300650 SITUATIONAL RULE: Required when needed to indicate if benefits are

considered In Plan Network or Out Of Plan Network for the
eligibility or benefits being identified in the 2110C loop. If not
required by this implementation guide, do not send.

OD: 271B1_2110C_EB12__InPlanNetworkIndicator

IMPLEMENTATION NAME: In Plan Network Indicator

300823 Use code “U” - Unknown, In the event that a payer typically
responds Yes or No for some benefits, but the inquired benefit
requirements are not accessible or the rules are more complex than
can be determined using the data sent in the 270.
CODE DEFINITION

N No
U Unknown
W Not Applicable
300973 Use code “W” - Not Applicable when benefits are
the same regardless of whether they are In Plan-
Network or Out of Plan-Network or a Plan-Network
does not apply to the benefit.
Y Yes
SITUATIONAL EB13 C003 COMPOSITE MEDICAL PROCEDURE O1
IDENTIFIER
To identify a medical procedure by its standardized codes and applicable
modifiers

300974 SITUATIONAL RULE: Requiredwhen a Medical Procedure Code was used

from the 270 to determine the response being identified in the
2110C loop;
OR
Required when the Information Source supports Medical Procedure
Code based 271 transactions and a Medical Procedure Code is
available and appropriate for the eligibility or benefits being
identified in the 2110C loop.
If not required by this implementation guide or if EB03 is used, do
not send.

OD: 271B1_2110C_EB13_C003

300824 Use this composite data element only if an information source can
support this high level of functionality. The EB13 allows for a very
specific response.

300857 Not used if EB03 is present.

APRIL 2008 303

005010X279 • 271 • 2110C • EB ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION TECHNICAL REPORT • TYPE 3

REQUIRED EB13 - 1 235 Product/Service ID Qualifier M ID 2/2

Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
SEMANTIC:
C003-01 qualifies C003-02 and C003-08.

OD:
271B1_2110C_EB13_C00301_ProductorServiceIDQualifier

IMPLEMENTATION NAME: Product or Service ID Qualifier

300470 Use this code to identify the external code list of the
following procedure/service code.
CODE DEFINITION

AD American Dental Association Codes

CODE SOURCE 135: American Dental Association
CJ Current Procedural Terminology (CPT) Codes
CODE SOURCE 133: Current Procedural Terminology (CPT) Codes
HC Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
CODE SOURCE 130: Healthcare Common Procedure Coding
System
ID International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) -
Procedure
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
IV Home Infusion EDI Coalition (HIEC) Product/Service
Code
300814 This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List
N4 National Drug Code in 5-4-2 Format
CODE SOURCE 240: National Drug Code by Format
ZZ Mutually Defined
301035 Use this code only for International Classification of
Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS).

CODE SOURCE 896: International Classification of

Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS)

304 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • EB
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

REQUIRED EB13 - 2 234 Product/Service ID M AN 1/48

Identifying number for a product or service
SEMANTIC:
If C003-08 is used, then C003-02 represents the beginning value in the
range in which the code occurs.

OD: 271B1_2110C_EB13_C00302_ProcedureCode

IMPLEMENTATION NAME: Procedure Code

300476 Use this ID number for the product/service code as qualified

by the preceding data element.
SITUATIONAL EB13 - 3 1339 Procedure Modifier O AN 2/2
This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-03 modifies the value in C003-02 and C003-08.

300975 SITUATIONAL RULE: Requiredwhen a modifier was used from the

270 to determine the response being identified in the 2110C
loop;
OR
Required when a modifier clarifies/improves the accuracy of
the associated procedure code and the modifier is available.
If not required by this implementation guide, do not send.

OD: 271B1_2110C_EB13_C00303_ProcedureModifier

300733 Use this modifier for the procedure code identified in EB13-
2 if modifiers are needed to further specify the service.

SITUATIONAL EB13 - 4 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-04 modifies the value in C003-02 and C003-08.

300975 SITUATIONAL RULE: Requiredwhen a modifier was used from the

270 to determine the response being identified in the 2110C
loop;
OR
Required when a modifier clarifies/improves the accuracy of
the associated procedure code and the modifier is available.
If not required by this implementation guide, do not send.

OD: 271B1_2110C_EB13_C00304_ProcedureModifier

300733 Use this modifier for the procedure code identified in EB13-
2 if modifiers are needed to further specify the service.

APRIL 2008 305

005010X279 • 271 • 2110C • EB ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL EB13 - 5 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-05 modifies the value in C003-02 and C003-08.

300975 SITUATIONAL RULE: Requiredwhen a modifier was used from the

270 to determine the response being identified in the 2110C
loop;
OR
Required when a modifier clarifies/improves the accuracy of
the associated procedure code and the modifier is available.
If not required by this implementation guide, do not send.

OD: 271B1_2110C_EB13_C00305_ProcedureModifier

300733 Use this modifier for the procedure code identified in EB13-
2 if modifiers are needed to further specify the service.
SITUATIONAL EB13 - 6 1339 Procedure Modifier O AN 2/2
This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-06 modifies the value in C003-02 and C003-08.

300975 SITUATIONAL RULE: Requiredwhen a modifier was used from the

270 to determine the response being identified in the 2110C
loop;
OR
Required when a modifier clarifies/improves the accuracy of
the associated procedure code and the modifier is available.
If not required by this implementation guide, do not send.

OD: 271B1_2110C_EB13_C00306_ProcedureModifier

300733 Use this modifier for the procedure code identified in EB13-
2 if modifiers are needed to further specify the service.

NOT USED EB13 - 7 352 Description O AN 1/80

SITUATIONAL EB13 - 8 234 Product/Service ID O AN 1/48
Identifying number for a product or service
SEMANTIC:
C003-08 represents the ending value in the range in which the code
occurs.

301062 SITUATIONAL RULE: Required

when the Information Source
desires to indicate a range of procedure codes. If not
required by this implementation guide, do not send.

OD: 271B1_2110C_EB13_C00308_ProductorServiceID

IMPLEMENTATION NAME: Product or Service ID

301063 EB13-2 indicates the beginning of value of the range of

procedure codes and EB13-8 represents the end of the
range of procedure codes. All procedure codes in the range
will apply.

306 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • EB
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

SITUATIONAL EB14 C004 COMPOSITE DIAGNOSIS CODE POINTER O1

To identify one or more diagnosis code pointers

300901 SITUATIONAL RULE: Requiredwhen a 2100C HI segment is used and the

information in this 2110C EB loop is related to a diagnosis code. If
2100C HI segment is not used or if the information in this 2110C EB
loop is not related to a diagnosis code, do not send.

OD: 271B1_2110C_EB14_C004

301064 See requirements for the use of the 2100C HI segment for
additional information.
REQUIRED EB14 - 1 1328 Diagnosis Code Pointer M N0 1/2
A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-01 identifies the primary diagnosis code for this service line.

OD: 271B1_2110C_EB14_C00401_DiagnosisCodePointer

300902 This first pointer designates the primary diagnosis for this
EB segment. Remaining diagnosis pointers indicate
declining level of importance to the EB segment.
Acceptable values are 1 through 8, and correspond to
Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100C.

SITUATIONAL EB14 - 2 1328 Diagnosis Code Pointer O N0 1/2

A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-02 identifies the second diagnosis code for this service line.

300903 SITUATIONAL RULE: Required when it is necessary to designate a

second diagnosis related to this EB segment. If not
required, do not send.

OD: 271B1_2110C_EB14_C00402_DiagnosisCodePointer

300904 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100C.
SITUATIONAL EB14 - 3 1328 Diagnosis Code Pointer O N0 1/2
A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-03 identifies the third diagnosis code for this service line.

300905 SITUATIONAL RULE: Required

when it is necessary to designate a
third diagnosis related to this EB segment. If not required,
do not send.

OD: 271B1_2110C_EB14_C00403_DiagnosisCodePointer

300904 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100C.

APRIL 2008 307

005010X279 • 271 • 2110C • EB ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL EB14 - 4 1328 Diagnosis Code Pointer O N0 1/2

A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-04 identifies the fourth diagnosis code for this service line.

300906 SITUATIONAL RULE: Required

when it is necessary to designate a
fourth diagnosis related to this EB segment. If not required,
do not send.

OD: 271B1_2110C_EB14_C00404_DiagnosisCodePointer

300904 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100C.

308 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • HSD
TECHNICAL REPORT • TYPE 3 HEALTH CARE SERVICES DELIVERY
HEALTH CARE SERVICES DELIVERY 005010X279
HEALTH CARE• 271 • 2110C •DELIVERY
SERVICES HSD
HSD

SEGMENT DETAIL
595
300
HSD - HEALTH CARE SERVICES DELIVERY
X12 Segment Name: Health Care Services Delivery
X12 Purpose: To specify the delivery pattern of health care services
X12 Syntax: 1. P0102
If either HSD01 or HSD02 is present, then the other is required.
2. C0605
If HSD06 is present, then HSD05 is required.
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 9

Usage: SITUATIONAL

36
06
30 Situational Rule: Required when needed to identify a specific delivery or usage pattern
associated with the benefits identified in either EB03 or EB13. If not
required by this implementation guide, do not send.

512
300 TR3 Example: HSD✽VS✽30✽✽✽22~
Thirty visits per service year

681
300 TR3 Example: HSD✽VS✽12✽WK✽3✽34✽1~
Twelve visits, three visits per week, for 1 month.

DIAGRAM

HSD01 673 HSD02 380 HSD03 355 HSD04 1167 HSD05 615 HSD06 616
Quantity Quantity Unit/Basis Sample Sel
✽ Time Period ✽ Number of
HSD ✽ Qualifier
✽ ✽
Meas Code
✽
Modulus Qualifier Periods
X1 ID 2/2 X1 R 1/15 O1 ID 2/2 O1 R 1/6 X1 ID 1/2 O1 N0 1/3

HSD07 678 HSD08 679

✽ Ship/Del or ✽ Ship/Del
~
Calend Code Time Code
O1 ID 1/2 O1 ID 1/1

APRIL 2008 309

005010X279 • 271 • 2110C • HSD ASC X12N • INSURANCE SUBCOMMITTEE
HEALTH CARE SERVICES DELIVERY TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

SITUATIONAL HSD01 673 Quantity Qualifier X1 ID 2/2

Code specifying the type of quantity
SYNTAX: P0102

300734 SITUATIONAL RULE: Required when identifying type and quantity benefits
identified. If not required by this implementation guide, do not send.

OD: 271B1_2110C_HSD01__QuantityQualifier

300735 Required if HSD02 is used.

CODE DEFINITION

DY Days
FL Units
HS Hours
MN Month
VS Visits
SITUATIONAL HSD02 380 Quantity X1 R 1/15
Numeric value of quantity
SYNTAX: P0102

300734 SITUATIONAL RULE: Required when identifying type and quantity benefits
identified. If not required by this implementation guide, do not send.

OD: 271B1_2110C_HSD02__BenefitQuantity

IMPLEMENTATION NAME: Benefit Quantity

300767 Required if HSD01 is used.

SITUATIONAL HSD03 355 Unit or Basis for Measurement Code O1 ID 2/2
Code specifying the units in which a value is being expressed, or manner in which
a measurement has been taken

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110C_HSD03__UnitorBasisforMeasurementCode

CODE DEFINITION

DA Days
MO Months
VS Visit
WK Week
YR Years

310 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • HSD
TECHNICAL REPORT • TYPE 3 HEALTH CARE SERVICES DELIVERY

SITUATIONAL HSD04 1167 Sample Selection Modulus O1 R 1/6

To specify the sampling frequency in terms of a modulus of the Unit of Measure,
e.g., every fifth bag, every 1.5 minutes

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110C_HSD04__SampleSelectionModulus

SITUATIONAL HSD05 615 Time Period Qualifier X1 ID 1/2

Code defining periods
SYNTAX: C0605

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110C_HSD05__TimePeriodQualifier

CODE DEFINITION

6 Hour
7 Day
21 Years
22 Service Year
23 Calendar Year
24 Year to Date
25 Contract
26 Episode
27 Visit
28 Outlier
29 Remaining
30 Exceeded
31 Not Exceeded
32 Lifetime
33 Lifetime Remaining
34 Month
35 Week
SITUATIONAL HSD06 616 Number of Periods O1 N0 1/3
Total number of periods
SYNTAX: C0605

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110C_HSD06__PeriodCount

IMPLEMENTATION NAME: Period Count

APRIL 2008 311

005010X279 • 271 • 2110C • HSD ASC X12N • INSURANCE SUBCOMMITTEE
HEALTH CARE SERVICES DELIVERY TECHNICAL REPORT • TYPE 3

SITUATIONAL HSD07 678 Ship/Delivery or Calendar Pattern Code O1 ID 1/2

Code which specifies the routine shipments, deliveries, or calendar pattern

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110C_HSD07__DeliveryFrequencyCode

IMPLEMENTATION NAME: Delivery Frequency Code

CODE DEFINITION

1 1st Week of the Month

2 2nd Week of the Month
3 3rd Week of the Month
4 4th Week of the Month
5 5th Week of the Month
6 1st & 3rd Weeks of the Month
7 2nd & 4th Weeks of the Month
8 1st Working Day of Period
9 Last Working Day of Period
A Monday through Friday
B Monday through Saturday
C Monday through Sunday
D Monday
E Tuesday
F Wednesday
G Thursday
H Friday
J Saturday
K Sunday
L Monday through Thursday
M Immediately
N As Directed
O Daily Mon. through Fri.
P 1/2 Mon. & 1/2 Thurs.
Q 1/2 Tues. & 1/2 Thurs.
R 1/2 Wed. & 1/2 Fri.
S Once Anytime Mon. through Fri.
SG Tuesday through Friday
SL Monday, Tuesday and Thursday
SP Monday, Tuesday and Friday
SX Wednesday and Thursday
SY Monday, Wednesday and Thursday
SZ Tuesday, Thursday and Friday
T 1/2 Tue. & 1/2 Fri.
U 1/2 Mon. & 1/2 Wed.
V 1/3 Mon., 1/3 Wed., 1/3 Fri.

312 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • HSD
TECHNICAL REPORT • TYPE 3 HEALTH CARE SERVICES DELIVERY

W Whenever Necessary
X 1/2 By Wed., Bal. By Fri.
Y None (Also Used to Cancel or Override a Previous
Pattern)
SITUATIONAL HSD08 679 Ship/Delivery Pattern Time Code O1 ID 1/1
Code which specifies the time for routine shipments or deliveries

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110C_HSD08__DeliveryPatternTimeCode

IMPLEMENTATION NAME: Delivery Pattern Time Code

CODE DEFINITION

A 1st Shift (Normal Working Hours)

B 2nd Shift
C 3rd Shift
D A.M.
E P.M.
F As Directed
G Any Shift
Y None (Also Used to Cancel or Override a Previous
Pattern)

APRIL 2008 313

 005010X279 • 271 • 2110C • REF ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3
REFERENCE INFORMATION SUBSCRIBER
005010X279 • 271 • 2110C •IDENTIFICATION
ADDITIONAL REF
REF

SEGMENT DETAIL
596
300
REF - SUBSCRIBER ADDITIONAL
IDENTIFICATION
X12 Segment Name: Reference Information
X12 Purpose: To specify identifying information
X12 Syntax: 1. R0203
At least one of REF02 or REF03 is required.
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 9

Usage: SITUATIONAL

76
09
30 Situational Rule: Required when the Information Source requires one or more of these
additional identifiers for subsequent EDI transactions (see Section 1.4.7);
OR
Required when an additional identifier is associated with the eligibility or
benefits being identified in the 2110C loop. If not required by this
implementation guide, do not send.

637
300 TR3 Notes: 1. Use this segment for reference identifiers related only to the 2110C
loop that it is contained in (e.g. Other or Additional Payer’s identifiers).

442
300 2. Use this segment to identify other or additional reference numbers for
the entity identified. The type of reference number is determined by
the qualifier in REF01. Only one occurrence of each REF01 code value
may be used in the 2110C loop.

513
300 TR3 Example: REF✽G1✽653745725~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

Reference Reference Description Reference
REF ✽ Ident Qual
✽
Ident
✽ ✽
Identifier ~
M1 ID 2/3 X1 AN 1/50 X1 AN 1/80 O1

314 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • REF
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ADDITIONAL IDENTIFICATION

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED REF01 128 Reference Identification Qualifier M1 ID 2/3

Code qualifying the Reference Identification

OD: 271B1_2110C_REF01__ReferenceIdentificationQualifier

300454 Use this code to specify or qualify the type of reference number
that is following in REF02, REF03, or both.

301029 Use “1W”, “49”, “F6”, and “NQ” only in a 2110C loop with EB01 =
“R”.

301065 Only one occurrence of each REF01 code value may be used in the
2110C loop.
CODE DEFINITION

18 Plan Number
1L Group or Policy Number
300622 Use this code only if it cannot be determined if the
number is a Group Number or a Policy number. Use
codes “IG” or “6P” when they can be determined.
1W Member Identification Number
49 Family Unit Number
300979 Required when the Information Source is a
Pharmacy Benefit Manager (PBM) and the individual
has a suffix to their member ID number that is
required for use in the NCPDP Telecom Standard in
the Insurance Segment in field 303-C3 Person Code.
If not required by this implementation Guide, do not
send.

NOTE: For all other uses, the Family Unit Number

(suffix) is considered a part of the Member ID
number and is used to uniquely identify the
individual and must be returned at the end of the
Member ID number in 2110C REF02 if REF01 is “1W”.
6P Group Number
9F Referral Number
ALS Alternative List ID
300977 Allows the source to identify the list identifier of a
list of drugs and its alternative drugs with the
associated formulary status for the patient.
CLI Coverage List ID
300978 Allows the source to identify the list identifier of a
list of drugs that have coverage limitations for the
associated patient.
F6 Health Insurance Claim (HIC) Number
FO Drug Formulary Number
G1 Prior Authorization Number
IG Insurance Policy Number

APRIL 2008 315

005010X279 • 271 • 2110C • REF ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3

M7 Medical Assistance Category

N6 Plan Network Identification Number
NQ Medicaid Recipient Identification Number
REQUIRED REF02 127 Reference Identification X1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: R0203

OD: 271B1_2110C_REF02__SubscriberEligibilityorBenefitIdentifier

IMPLEMENTATION NAME: Subscriber Eligibility or Benefit Identifier

300453 Use this information for the reference number as qualified by the
preceding data element (REF01).
SITUATIONAL REF03 352 Description X1 AN 1/80
A free-form description to clarify the related data elements and their content
SYNTAX: R0203

300864 SITUATIONAL RULE: Required when REF01 = “18", ”6P" or “N6" and a
name needs to be associated with the corresponding identifier. If
not required by this implementation guide, do not send.

OD: 271B1_2110C_REF03__PlanGrouporPlanNetworkName

IMPLEMENTATION NAME: Plan, Group or Plan Network Name

NOT USED REF04 C040 REFERENCE IDENTIFIER O1

316 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • DTP
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY/BENEFIT DATE
DATE OR TIME OR PERIOD SUBSCRIBER
005010X279 • 271 • 2110C • DTP
ELIGIBILITY/BENEFIT DATE
DTP

SEGMENT DETAIL
597
300
DTP - SUBSCRIBER ELIGIBILITY/BENEFIT
DATE
X12 Segment Name: Date or Time or Period
X12 Purpose: To specify any or all of a date, a time, or a time period
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 20

Usage: SITUATIONAL

23
06
30 Situational Rule: Required when the individual has active coverage with multiple plans or
multiple plan periods apply (See 2100C DTP segment);
OR
Required when needed to convey dates associated with the eligibility or
benefits being identified in the 2110C loop.
If not required by this implementation guide, do not send.

825
300 TR3 Notes: 1. When using the DTP segment in the 2110C loop this date applies only
to the 2110C Eligibility or Benefit Information (EB) loop in which it is
located.

If a DTP segment with the same DTP01 value is present in the 2100C
loop, the date is overridden for only this 2110C Eligibility or Benefit
Information (EB) loop.

496
300 TR3 Example: DTP✽472✽D8✽19960624~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251

Date/Time
✽ Date Time ✽ Date Time
DTP ✽ Qualifier Format Qual Period ~
M1 ID 3/3 M1 ID 2/3 M1 AN 1/35

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED DTP01 374 Date/Time Qualifier M1 ID 3/3

Code specifying type of date or time, or both date and time

OD: 271B1_2110C_DTP01__DateTimeQualifier

IMPLEMENTATION NAME: Date Time Qualifier

CODE DEFINITION

096 Discharge
193 Period Start
194 Period End
198 Completion
290 Coordination of Benefits

APRIL 2008 317

005010X279 • 271 • 2110C • DTP ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY/BENEFIT DATE TECHNICAL REPORT • TYPE 3

291 Plan
301066 Use code 291 only if multiple plans apply to the
individual or multiple plan periods apply. Dates
supplied in this DPT segment only apply to the
2110C loop in which it occurs.
292 Benefit
295 Primary Care Provider
304 Latest Visit or Consultation
307 Eligibility
318 Added
346 Plan Begin
301067 Use code 346 only if multiple plans apply to the
individual or multiple plan periods apply. Dates
supplied in this DPT segment only apply to the
2110C loop in which it occurs.
348 Benefit Begin
349 Benefit End
356 Eligibility Begin
357 Eligibility End
435 Admission
472 Service
636 Date of Last Update
771 Status
REQUIRED DTP02 1250 Date Time Period Format Qualifier M1 ID 2/3
Code indicating the date format, time format, or date and time format
SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

OD: 271B1_2110C_DTP02__DateTimePeriodFormatQualifier

300463 Use this code to specify the format of the date(s)/time(s) that follow
in the next data element.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

RD8 Range of Dates Expressed in Format CCYYMMDD-
CCYYMMDD
REQUIRED DTP03 1251 Date Time Period M 1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times

OD: 271B1_2110C_DTP03__EligibilityorBenefitDateTimePeriod

IMPLEMENTATION NAME: Eligibility or Benefit Date Time Period

300462 Use this date for the date(s) as qualified by the preceding data
elements.

318 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • AAA
TECHNICAL REPORT • TYPE 3 SUBSCRIBER REQUEST VALIDATION
REQUEST VALIDATION SUBSCRIBER
005010X279 • 271 • 2110CVALIDATION
REQUEST • AAA
AAA

SEGMENT DETAIL
591
300
AAA - SUBSCRIBER REQUEST VALIDATION
X12 Segment Name: Request Validation
X12 Purpose: To specify the validity of the request and indicate follow-up action authorized
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 9

Usage: SITUATIONAL

37
07
30 Situational Rule: Required when the request could not be processed at a system or
application level when specifically related to specific eligibility/benefit
inquiry data contained in the original 270 transaction’s subscriber
eligibility/benefit inquiry information loop (Loop 2110C) and to indicate
what action the originator of the request transaction should take. If not
required by this implementation guide, do not send.

738
300 TR3 Notes: 1. Use this segment to indicate problems in processing the transaction
specifically related to specific eligibility/benefit inquiry data contained
in the original 270 transaction’s subscriber eligibility/benefit inquiry
information loop (Loop 2110C).

497
300 TR3 Example: AAA✽N✽✽70✽C~

DIAGRAM

AAA01 1073 AAA02 559 AAA03 901 AAA04 889

✽ Yes/No Cond ✽ Agency Reject Follow-up

AAA Resp Code Qual Code
✽
Reason Code
✽
Act Code ~
M1 ID 1/1 O1 ID 2/2 O1 ID 2/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED AAA01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: AAA01 designates whether the request is valid or invalid. Code “Y”
indicates that the code is valid; code “N” indicates that the code is invalid.

OD: 271B1_2110C_AAA01__ValidRequestIndicator

IMPLEMENTATION NAME: Valid Request Indicator

CODE DEFINITION

N No
300561 Use this code to indicate that the request or an
element in the request is not valid. The transaction
has been rejected as identified by the code in
AAA03.

APRIL 2008 319

005010X279 • 271 • 2110C • AAA ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER REQUEST VALIDATION TECHNICAL REPORT • TYPE 3

Y Yes
300562 Use this code to indicate that the request is valid,
however the transaction has been rejected as
identified by the code in AAA03.
NOT USED AAA02 559 Agency Qualifier Code O1 ID 2/2
REQUIRED AAA03 901 Reject Reason Code O1 ID 2/2
Code assigned by issuer to identify reason for rejection

OD: 271B1_2110C_AAA03__RejectReasonCode

300438 Use this code for the reason why the transaction was unable to be
processed successfully. This may indicate problems with the
system, the application, or the data content.
CODE DEFINITION

15 Required application data missing

33 Input Errors
300865 Use this code only when data is present in this
transaction and no other Reject Reason Code is
valid for describing the error. Detail of the error
must be supplied in the MSG segment of the 2110C
loop containing this Reject Reason Code.
52 Service Dates Not Within Provider Plan Enrollment
53 Inquired Benefit Inconsistent with Provider Type
54 Inappropriate Product/Service ID Qualifier
55 Inappropriate Product/Service ID
56 Inappropriate Date
57 Invalid/Missing Date(s) of Service
60 Date of Birth Follows Date(s) of Service
61 Date of Death Precedes Date(s) of Service
62 Date of Service Not Within Allowable Inquiry Period
63 Date of Service in Future
69 Inconsistent with Patient’s Age
70 Inconsistent with Patient’s Gender
98 Experimental Service or Procedure
AA Authorization Number Not Found
300866 Use this code only when the Referral Number or
Prior Authorization Number in 2110C REF02 is not
found.
AE Requires Primary Care Physician Authorization
AF Invalid/Missing Diagnosis Code(s)
AG Invalid/Missing Procedure Code(s)
300867 Use this code for errors with Procedure Codes in
EQ02-2 or Procedure Code Modifiers in EQ02-3
through EQ02-6.

320 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • AAA
TECHNICAL REPORT • TYPE 3 SUBSCRIBER REQUEST VALIDATION

AO Additional Patient Condition Information Required

300868 Use this code only if the Information Source
supports responding to a detailed eligibility request
and the information can be processed from a 270
transaction received by the Information Source but
was not received and is needed to respond
appropriately.
CI Certification Information Does Not Match Patient
300869 Use this code only when the Referral Number or
Prior Authorization Number in 2110C REF02 is
found but is not associated with the subscriber.
E8 Requires Medical Review
IA Invalid Authorization Number Format
300870 Use this code only when the Referral Number or
Prior Authorization Number in 2110C REF02 is not
formatted properly.
MA Missing Authorization Number
300871 Use this code only when the Referral Number or
Prior Authorization Number has been issued and is
missing in 2110C REF02 but is needed to respond
appropriately.
REQUIRED AAA04 889 Follow-up Action Code O1 ID 1/1
Code identifying follow-up actions allowed

OD: 271B1_2110C_AAA04__FollowupActionCode

300437 Use this code to instruct the recipient of the 271 about what action
needs to be taken, if any, based on the validity code and the reject
reason code (if applicable).
CODE DEFINITION

C Please Correct and Resubmit

N Resubmission Not Allowed
R Resubmission Allowed
W Please Wait 30 Days and Resubmit
X Please Wait 10 Days and Resubmit
Y Do Not Resubmit; We Will Hold Your Request and
Respond Again Shortly

APRIL 2008 321

 005010X279 • 271 • 2110C • MSG ASC X12N • INSURANCE SUBCOMMITTEE
MESSAGE TEXT TECHNICAL REPORT • TYPE 3
MESSAGE TEXT • 271 • 2110C • MSG
005010X279TEXT
MESSAGE
MSG

SEGMENT DETAIL
598
300
MSG - MESSAGE TEXT
X12 Segment Name: Message Text
X12 Purpose: To provide a free-form format that allows the transmission of text information
X12 Syntax: 1. C0302
If MSG03 is present, then MSG02 is required.
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 10

Usage: SITUATIONAL

80
09
30 Situational Rule: Required when the eligibility or benefit information cannot be codified in
existing data elements (including combinations of multiple data elements
and segments);
AND
Required when this information is pertinent to the eligibility or benefit
response.
If not required by this implementation guide, do not send.

504
300 TR3 Notes: 1. Free form text or description fields are not recommended because
they require human interpretation.

858
300 2. Under no circumstances can an information source use the MSG
segment to relay information that can be sent using codified
information in existing data elements (including combinations of
multiple data elements and segments). If the information cannot be
codified, then cautionary use of the MSG segment is allowed as a
short term solution. It is highly recommended that the entity needing
to use the MSG segment approach X12N with data maintenance to
solve the long term business need, so the use of the MSG segment
can be avoided for that issue.

683
300 3. Benefit Disclaimers are strongly discouraged. See section 1.4.11
Disclaimers Within the Transaction. Under no circumstances are more
than one MSG segment to be used for a Benefit Disclaimer per
individual response.

682
300 TR3 Example: MSG✽Free form text is discouraged~

DIAGRAM

MSG01 933 MSG02 934 MSG03 1470

Free-Form Printer Number
MSG ✽
Message Txt
✽
Ctrl Code
✽ ~
M1 AN 1/264 X1 ID 2/2 O1 N0 1/9

322 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110C • MSG
TECHNICAL REPORT • TYPE 3 MESSAGE TEXT

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED MSG01 933 Free-form Message Text M 1 AN 1/264

Free-form message text

OD: 271B1_2110C_MSG01__FreeFormMessageText

IMPLEMENTATION NAME: Free Form Message Text

NOT USED MSG02 934 Printer Carriage Control Code X1 ID 2/2
NOT USED MSG03 1470 Number O1 N0 1/9

APRIL 2008 323

 005010X279 • 271 • 2115C • III ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION TECHNICAL REPORT • TYPE 3
INFORMATION SUBSCRIBER
005010X279 • 271 • 2115C OR
ELIGIBILITY • III BENEFIT ADDITIONAL INFORMATION
III

SEGMENT DETAIL
684
300
III - SUBSCRIBER ELIGIBILITY OR BENEFIT
ADDITIONAL INFORMATION
X12 Segment Name: Information
X12 Purpose: To report information
X12 Syntax: 1. P0102
If either III01 or III02 is present, then the other is required.
2. L030405
If III03 is present, then at least one of III04 or III05 are required.
Loop: 2115C — SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL
INFORMATION Loop Repeat: 10

Segment Repeat: 1

Usage: SITUATIONAL

86
06
30 Situational Rule: Required when III segments in Loop 2110C of the 270 Inquiry were used in
the determination of the eligibility or benefit response;
OR
Required when needed to identify limitations in the benefits explained in
the corresponding Loop 2110C (such as if benefits are limited to a type of
facility).
If not required by this implementation guide, do not send.

687
300 TR3 Notes: 1. This segment has two purposes. Information that was received in III
segments in Loop 2110C of the 270 Inquiry and was used in the
determination of the eligibility or benefit response must be returned.
If information was provided in III segments of Loop 2110C but was not
used in the determination of the eligibility or benefits it must not be
returned. This segment can also be used to identify limitations in the
benefits explained in the corresponding Loop 2110C, such as if
benefits are limited to a type of facility.

688
300 2. Use this segment to identify Nature of Injury Codes and/or Facility
Type as they relate to the information provided in the EB segment.

689
300 3. Use the III segment only if an information source can support this
high level functionality.

690
300 4. Use this segment only one time for the Facility Type Code.

685
300 TR3 Example: III✽ZZ✽21~
III✽✽✽44✽Broken bones and third degree burns~

324 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2115C • III
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION

DIAGRAM

III01 1270 III02 1271 III03 1136 III04 933 III05 380 III06 C001
Code List Industry Code
✽ Free-Form ✽ Quantity Composite
III ✽ Qual Code
✽
Code
✽
Category Message Txt
✽
Unit of Mea
X1 ID 1/3 X1 AN 1/30 O1 ID 2/2 X1 AN 1/264 X1 R 1/15 O1

III07 752 III08 752 III09 752

Layer/Posit Layer/Posit Layer/Posit
✽ ✽ ✽ ~
Code Code Code
O1 ID 2/2 O1 ID 2/2 O1 ID 2/2

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

SITUATIONAL III01 1270 Code List Qualifier Code X1 ID 1/3

Code identifying a specific industry code list
SYNTAX: P0102

300981 SITUATIONAL RULE: Requiredwhen identifying a Nature of Injury Code or

a Facility Type Code. If not required by this implementation guide,
do not send.

OD: 271B1_2115C_III01__CodeListQualifierCode

300872 Use this code to specify if the code that is following in the III02 is a
Nature of Injury Code or a Facility Type Code.
CODE DEFINITION

GR National Council on Compensation Insurance (NCCI)

Nature of Injury Code
CODE SOURCE 284: Nature of Injury Code
NI Nature of Injury Code
300873 Other code source as specified by the jurisdiction.
CODE SOURCE 284: Nature of Injury Code
CODE SOURCE 407: Occupational Injury and Illness Classification
Manual
ZZ Mutually Defined
300739 Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of
Service Codes for Professional Claims.
SITUATIONAL III02 1271 Industry Code X1 AN 1/30
Code indicating a code from a specific industry code list
SYNTAX: P0102

300981 SITUATIONAL RULE: Required when identifying a Nature of Injury Code or

a Facility Type Code. If not required by this implementation guide,
do not send.

OD: 271B1_2115C_III02__IndustryCode

300874 If III01 is GR, use this element for NCCI Nature of Injury code from
code source 284.

APRIL 2008 325

005010X279 • 271 • 2115C • III ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION TECHNICAL REPORT • TYPE 3

300875 If III01 is NI, use this element for Nature of Injury code from code
source 407.

300691 If III01 is ZZ, use this element for codes identifying a place of
service from code source 237. As a courtesy, the codes are listed
below, however, the code list is thought to be complete at the time
of publication of this implementation guideline. Since this list is
subject to change, only codes contained in the document available
from code source 237 are to be supported in this transaction and
take precedence over any and all codes listed here.

01 Pharmacy
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-based Facility
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service

326 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2115C • III
TECHNICAL REPORT • TYPE 3 SUBSCRIBER ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION

SITUATIONAL III03 1136 Code Category O1 ID 2/2

Specifies the situation or category to which the code applies
SYNTAX: L030405
SEMANTIC: III03 is used to categorize III04.

300876 SITUATIONAL RULE: Required when III01 and III02 are not present or if
additional information is needed (see III04). If not required by this
implementation guide or if III01 is ZZ, do not send.

OD: 271B1_2115C_III03__CodeCategory

CODE DEFINITION

44 Nature of Injury
SITUATIONAL III04 933 Free-form Message Text X1 AN 1/264
Free-form message text
SYNTAX: L030405

300877 SITUATIONAL RULE: Required

when III03 = “44”. If not required by this
implementation guide, do not send.

OD: 271B1_2115C_III04__InjuredBodyPartName

IMPLEMENTATION NAME: Injured Body Part Name

300878 Use this element to describe the injured body part or parts.

NOT USED III05 380 Quantity X1 R 1/15

NOT USED III06 C001 COMPOSITE UNIT OF MEASURE O1
NOT USED III07 752 Surface/Layer/Position Code O1 ID 2/2
NOT USED III08 752 Surface/Layer/Position Code O1 ID 2/2
NOT USED III09 752 Surface/Layer/Position Code O1 ID 2/2

APRIL 2008 327

 005010X279 • 271 • 2110C • LS ASC X12N • INSURANCE SUBCOMMITTEE
LOOP HEADER TECHNICAL REPORT • TYPE 3
LOOP HEADER 005010X279
LOOP HEADER• 271 • 2110C • LS
LS

SEGMENT DETAIL
599
300
LS - LOOP HEADER
X12 Segment Name: Loop Header
X12 Purpose: To indicate that the next segment begins a loop
X12 Semantic: 1. One loop may be nested contained within another loop, provided the inner
nested loop terminates before the outer loop. When specified by the
standard setting body as mandatory, this segment in combination with “LE”,
must be used. It is not to be used if not specifically set forth for use. The
loop identifier in the loop header and trailer must be identical. The value for
the identifier is the loop ID of the required loop segment. The loop ID
number is given on the transaction set diagram in the appropriate ASC X12
version/release.
X12 Comments: 1. See Figures Appendix for an explanation of the use of the LS and LE
segments.
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 1

Usage: SITUATIONAL

82
09
30 Situational Rule: Required when Loop 2120C is used. If not required by this implementation
guide, do not send.

740
300 TR3 Notes: 1. Use this segment to identify the beginning of the Subscriber Benefit
Related Entity Name loop. Because both the subscriber’s name loop
and this loop begin with NM1 segments, the LS and LE segments are
used to differentiate these two loops.

804
300 TR3 Example: LS✽2120~

DIAGRAM

LS01 447
Loop ID
LS ✽ Code
M1 AN 1/4

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED LS01 447 Loop Identifier Code M 1 AN 1/4

The loop ID number given on the transaction set diagram is the value for this data
element in segments LS and LE

OD: 271B1_2110C_LS01__LoopIdentifierCode

300805 This data element must have the value of “2120”.

328 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120C • NM1
TECHNICAL REPORT • TYPE 3 SUBSCRIBER BENEFIT RELATED ENTITY NAME
INDIVIDUAL OR ORGANIZATIONAL NAME 005010X279
SUBSCRIBER • 271 • 2120C
BENEFIT • NM1 ENTITY NAME
RELATED
NM1

SEGMENT DETAIL
546
300
NM1 - SUBSCRIBER BENEFIT RELATED
ENTITY NAME
X12 Segment Name: Individual or Organizational Name
X12 Purpose: To supply the full name of an individual or organizational entity
X12 Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
3. C1203
If NM112 is present, then NM103 is required.
Loop: 2120C — SUBSCRIBER BENEFIT RELATED ENTITY NAME Loop
Repeat: 23

Segment Repeat: 1

Usage: SITUATIONAL

41
07
30 Situational Rule: Required when provider was identified in 2100C PRV02 and PRV03 by
Identification Number (not Taxonomy Code) in the 270 Inquiry and was
used in the determination of the eligibility or benefit response;
OR
Required when needed to identify an entity associated with the eligibility
or benefits being identified in the 2110C loop such as a provider (e.g.
primary care provider), an individual, an organization, another payer, or
another information source;
If not required by this implementation guide, do not send.

499
300 TR3 Example: NM1✽P3✽1✽JONES✽MARCUS✽✽✽MD✽SV✽111223333~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038
Entity ID Entity Type Name Last/ Name Name Name
NM1 ✽ Code
✽
Qualifier
✽
Org Name
✽
First
✽
Middle
✽
Prefix
M1 ID 2/3 M1 ID 1/1 X1 AN 1/60 O1 AN 1/35 O1 AN 1/25 O1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

Name ID Code ID Entity Entity ID Name Last/
✽ ✽ ✽ ✽ ✽ ✽ ~
Suffix Qualifier Code Relat Code Code Org Name
O1 AN 1/10 X1 ID 1/2 X1 AN 2/80 X1 ID 2/2 O1 ID 2/3 O1 AN 1/60

APRIL 2008 329

005010X279 • 271 • 2120C • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER BENEFIT RELATED ENTITY NAME TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED NM101 98 Entity Identifier Code M1 ID 2/3

Code identifying an organizational entity, a physical location, property or an
individual

OD: 271B1_2120C_NM101__EntityIdentifierCode

CODE DEFINITION

13 Contracted Service Provider

1I Preferred Provider Organization (PPO)
300983 Use if identifying a Preferred Provider Organization
(PPO) by name or identification number. May also
be used if identifying the Network that benefits are
restricted to when 2110C EB12 = “Y” (In-Network).
1P Provider
2B Third-Party Administrator
36 Employer
73 Other Physician
FA Facility
GP Gateway Provider
GW Group
I3 Independent Physicians Association (IPA)
IL Insured or Subscriber
300692 Use if identifying an insured or subscriber to a plan
other than the information source (such as in a co-
ordination of benefits situation).
LR Legal Representative
OC Origin Carrier
300826 Use if identifying an organization that added
information relating to other insurance.
P3 Primary Care Provider
P4 Prior Insurance Carrier
P5 Plan Sponsor
PR Payer
PRP Primary Payer
SEP Secondary Payer
TTP Tertiary Payer
VN Vendor
VY Organization Completing Configuration Change
300827 Use if identifying an organization that changed
information relating to other insurance.
X3 Utilization Management Organization

330 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120C • NM1
TECHNICAL REPORT • TYPE 3 SUBSCRIBER BENEFIT RELATED ENTITY NAME

REQUIRED NM102 1065 Entity Type Qualifier M1 ID 1/1

Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.

OD: 271B1_2120C_NM102__EntityTypeQualifier

300440 Use this code to indicate whether the entity is an individual person
or an organization.
CODE DEFINITION

1 Person
2 Non-Person Entity
SITUATIONAL NM103 1035 Name Last or Organization Name X1 AN 1/60
Individual last name or organizational name
SYNTAX: C1203

300984 SITUATIONAL RULE: Requiredwhen needed to identify by name an entity

associated with the eligibility or benefits being identified in the
2110C loop such as a provider (e.g. Primary Care Provider), an
individual, an organization, another payer, or another information
source
OR
Required when NM109 is not used.
If not required by this implementation guide, do not send.

OD:
271B1_2120C_NM103__BenefitRelatedEntityLastorOrganizationName

IMPLEMENTATION NAME: Benefit Related Entity Last or Organization Name

300449 Use this name for the organization name if the entity type qualifier
is a non-person entity. Otherwise, this will be the individual’s last
name.
SITUATIONAL NM104 1036 Name First O 1 AN 1/35
Individual first name

300651 SITUATIONAL RULE: Required when NM102 is “1" and NM103 is used. If
not required by this implementation guide, do not send.

OD: 271B1_2120C_NM104__BenefitRelatedEntityFirstName

IMPLEMENTATION NAME: Benefit Related Entity First Name

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25
Individual middle name or initial

300985 SITUATIONAL RULE: Required when NM102 is “1" and the Last Name in
NM103 and First Name in NM104 are not sufficient to identify the
individual. If not required by this implementation guide, may be
provided at sender’s discretion, but cannot be required by the
receiver.

OD: 271B1_2120C_NM105__BenefitRelatedEntityMiddleName

IMPLEMENTATION NAME: Benefit Related Entity Middle Name

NOT USED NM106 1038 Name Prefix O 1 AN 1/10

APRIL 2008 331

005010X279 • 271 • 2120C • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER BENEFIT RELATED ENTITY NAME TECHNICAL REPORT • TYPE 3

SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10

Suffix to individual name

300647 SITUATIONAL RULE: Required

when NM102 is “1" and the Last Name in
NM103 and First Name in NM104 and/or Middle Name in 2100A
NM105 are not sufficient to identify the individual. If not required by
this implementation guide, may be provided at sender’s discretion,
but cannot be required by the receiver.

OD: 271B1_2120C_NM107__BenefitRelatedEntityNameSuffix

IMPLEMENTATION NAME: Benefit Related Entity Name Suffix

301036 Use for name suffix only (e.g. Sr, Jr, II, III, etc.).
SITUATIONAL NM108 66 Identification Code Qualifier X1 ID 1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX: P0809

300986 SITUATIONAL RULE: Requiredwhen needed to identify by Identification

Code an entity associated with the eligibility or benefits being
identified in the 2110C loop such as a provider (e.g. Primary Care
Provider), an individual, an organization, another payer, or another
information source.
OR
Required when NM103 is not used.
If not required by this implementation guide, may be provided at
sender’s discretion, but cannot be required by the receiver.

OD: 271B1_2120C_NM108__IdentificationCodeQualifier

300624 If the entity being identified is a provider and the National Provider
ID is mandated for use, code value “XX” must be used, otherwise,
one of the other codes may be used. If the entity being identified is
a payer and the CMS National PlanID is mandated for use, code
value “XV” must be used, otherwise, one of the other codes may be
used. If the entity being identified is an individual, the “HIPAA
Individual Identifier” must be used once this identifier has been
adopted, otherwise, one of the other codes may be used.
CODE DEFINITION

24 Employer’s Identification Number

34 Social Security Number
300658 The social security number may not be used for any
Federally administered programs such as Medicare.
46 Electronic Transmitter Identification Number (ETIN)
FA Facility Identification
FI Federal Taxpayer’s Identification Number
II Standard Unique Health Identifier for each Individual
in the United States
301068 Under the Health Insurance Portability and
Accountability Act of 1996, the Secretary of the
Department of Health and Human Services may
adopt a standard individual identifier for use in this
transaction.

332 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120C • NM1
TECHNICAL REPORT • TYPE 3 SUBSCRIBER BENEFIT RELATED ENTITY NAME

MI Member Identification Number

300705 Use this code to identify the entity’s Member
Identification Number associated with a payer other
than the information source in Loop 2100A. This
code may only be used prior to the mandated use of
code “II”.
NI National Association of Insurance Commissioners
(NAIC) Identification
PI Payor Identification
PP Pharmacy Processor Number
SV Service Provider Number
XV Centers for Medicare and Medicaid Services PlanID
CODE SOURCE 540: Centers for Medicare and Medicaid Services
PlanID
XX Centers for Medicare and Medicaid Services
National Provider Identifier
CODE SOURCE 537: Centers for Medicare & Medicaid Services
National Provider Identifier
SITUATIONAL NM109 67 Identification Code X1 AN 2/80
Code identifying a party or other code
SYNTAX: P0809

300986 SITUATIONAL RULE: Requiredwhen needed to identify by Identification

Code an entity associated with the eligibility or benefits being
identified in the 2110C loop such as a provider (e.g. Primary Care
Provider), an individual, an organization, another payer, or another
information source.
OR
Required when NM103 is not used.
If not required by this implementation guide, may be provided at
sender’s discretion, but cannot be required by the receiver.

OD: 271B1_2120C_NM109__BenefitRelatedEntityIdentifier

IMPLEMENTATION NAME: Benefit Related Entity Identifier

300448 Use this code for the reference number as qualified by the
preceding data element (NM108).

APRIL 2008 333

005010X279 • 271 • 2120C • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER BENEFIT RELATED ENTITY NAME TECHNICAL REPORT • TYPE 3

SITUATIONAL NM110 706 Entity Relationship Code X1 ID 2/2

Code describing entity relationship
SYNTAX: C1110
COMMENT: NM110 and NM111 further define the type of entity in NM101.

300837 SITUATIONAL RULE: Required

when needed to indicate the Benefit
Related Entity’s relationship to the patient when EB01 = “R”, the
coverage is based on the Benefit Related Entity and the
relationship is known. If not required by this implementation guide,
may be provided at sender’s discretion, but cannot be required by
the receiver.

OD: 271B1_2120C_NM110__BenefitRelatedEntityRelationshipCode

IMPLEMENTATION NAME: Benefit Related Entity Relationship Code

CODE DEFINITION

01 Parent
02 Child
27 Domestic Partner
41 Spouse
48 Employee
65 Other
72 Unknown
NOT USED NM111 98 Entity Identifier Code O1 ID 2/3
NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

334 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120C • N3
TECHNICAL REPORT • TYPE 3 SUBSCRIBER BENEFIT RELATED ENTITY ADDRESS
PARTY LOCATION SUBSCRIBER
005010X279 • 271 • 2120C
BENEFIT • N3 ENTITY ADDRESS
RELATED
N3

SEGMENT DETAIL
547
300
N3 - SUBSCRIBER BENEFIT RELATED
ENTITY ADDRESS
X12 Segment Name: Party Location
X12 Purpose: To specify the location of the named party
Loop: 2120C — SUBSCRIBER BENEFIT RELATED ENTITY NAME

Segment Repeat: 1

Usage: SITUATIONAL

42
07
30 Situational Rule: Required when needed to further identify the entity or individual in loop
2120C NM1 and the information is available. If not required by this
implementation guide, do not send.

444
300 TR3 Notes: 1. Use this segment to identify address information for an entity.

485
300 TR3 Example: N3✽201 PARK AVENUE✽SUITE 300~

DIAGRAM

N301 166 N302 166

Address Address
N3 ✽ Information
✽
Information ~
M1 AN 1/55 O1 AN 1/55

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N301 166 Address Information M 1 AN 1/55

Address information

OD: 271B1_2120C_N301__BenefitRelatedEntityAddressLine

IMPLEMENTATION NAME: Benefit Related Entity Address Line

300455 Use this information for the first line of the address information.

SITUATIONAL N302 166 Address Information O 1 AN 1/55

Address information

300708 SITUATIONAL RULE: Requiredwhen a second address line exists and is

available. If not required by this implementation guide, do not send.

OD: 271B1_2120C_N302__BenefitRelatedEntityAddressLine

IMPLEMENTATION NAME: Benefit Related Entity Address Line

300456 Use this information for the second line of the address information.

APRIL 2008 335

 005010X279 • 271 • 2120C • N4 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER BENEFIT RELATED ENTITY CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3
GEOGRAPHIC LOCATION SUBSCRIBER
005010X279 • 271 • 2120C
BENEFIT • N4 ENTITY CITY, STATE, ZIP CODE
RELATED
N4

SEGMENT DETAIL
548
300
N4 - SUBSCRIBER BENEFIT RELATED
ENTITY CITY, STATE, ZIP CODE
X12 Segment Name: Geographic Location
X12 Purpose: To specify the geographic place of the named party
X12 Syntax: 1. E0207
Only one of N402 or N407 may be present.
2. C0605
If N406 is present, then N405 is required.
3. C0704
If N407 is present, then N404 is required.
Loop: 2120C — SUBSCRIBER BENEFIT RELATED ENTITY NAME

Segment Repeat: 1

Usage: SITUATIONAL

37
10
30 Situational Rule: Required when needed to further identify the entity or individual in loop
2120C NM1 and the information is available. If not required by this
implementation guide, do not send.

038
301 TR3 Notes: 1. Use this segment to identify address information for an entity.

920
300 TR3 Example: N4✽KANSAS CITY✽MO✽64108~

DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310
City State or Postal Country Location Location
N4 ✽ Name
✽
Prov Code
✽
Code
✽
Code
✽
Qualifier
✽
Identifier
O1 AN 2/30 X1 ID 2/2 O1 ID 3/15 X1 ID 2/3 X1 ID 1/2 O1 AN 1/30

N407 1715

✽ Country Sub ~
Code
X1 ID 1/3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N401 19 City Name O 1 AN 2/30

Free-form text for city name
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.

OD: 271B1_2120C_N401__BenefitRelatedEntityCityName

IMPLEMENTATION NAME: Benefit Related Entity City Name

336 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120C • N4
TECHNICAL REPORT • TYPE 3 SUBSCRIBER BENEFIT RELATED ENTITY CITY, STATE, ZIP CODE

SITUATIONAL N402 156 State or Province Code X1 ID 2/2

Code (Standard State/Province) as defined by appropriate government agency
SYNTAX: E0207
COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

300921 SITUATIONAL RULE: Required

when the address is in the United States of
America, including its territories, or Canada. If not required by this
implementation guide, do not send.

OD: 271B1_2120C_N402__BenefitRelatedEntityStateCode

IMPLEMENTATION NAME: Benefit Related Entity State Code

CODE SOURCE 22: States and Provinces

SITUATIONAL N403 116 Postal Code O1 ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)

300922 SITUATIONAL RULE: Requiredwhen the address is in the United States of

America, including its territories, or Canada, or when a postal code
exists for the country in N404. If not required by this
implementation guide, do not send.

OD: 271B1_2120C_N403__BenefitRelatedEntityPostalZoneorZIPCode

IMPLEMENTATION NAME: Benefit Related Entity Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes
SITUATIONAL N404 26 Country Code X1 ID 2/3
Code identifying the country
SYNTAX: C0704

300923 SITUATIONAL RULE: Required

when the address is outside the United
States of America. If not required by this implementation guide, do
not send.

OD: 271B1_2120C_N404__BenefitRelatedEntityCountryCode

IMPLEMENTATION NAME: Benefit Related Entity Country Code

CODE SOURCE 5: Countries, Currencies and Funds

300924 Use the alpha-2 country codes from Part 1 of ISO 3166.

APRIL 2008 337

005010X279 • 271 • 2120C • N4 ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER BENEFIT RELATED ENTITY CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL N405 309 Location Qualifier X1 ID 1/2

Code identifying type of location
SYNTAX: C0605

301027 SITUATIONAL RULE: Required

when needed by CHAMPUS/TRICARE or
CHAMPVA to communicate the DOD Health Service Region. If not
required by this implementation guide, do not send.

OD: 271B1_2120C_N405__BenefitRelatedEntityLocationQualifier

IMPLEMENTATION NAME: Benefit Related Entity Location Qualifier

CODE SOURCE 206: Government Bill of Lading Office Code

301039 Use this element only to communicate the Department of Defense

Health Service Region.
CODE DEFINITION

RJ Region
300693 Use this code only to communicate the Department
of Defense Health Service Region in N406.
SITUATIONAL N406 310 Location Identifier O 1 AN 1/30
Code which identifies a specific location
SYNTAX: C0605

301027 SITUATIONAL RULE: Required

when needed by CHAMPUS/TRICARE or
CHAMPVA to communicate the DOD Health Service Region. If not
required by this implementation guide, do not send.

OD:
271B1_2120C_N406__BenefitRelatedEntityDODHealthServiceRegion

IMPLEMENTATION NAME: Benefit Related Entity DOD Health Service Region

301028 Use this element only to communicate the Department of Defense

Health Service Region.

301040 CODE SOURCE DOD1: Military Health Systems Functional Area

Manual - Data.

SITUATIONAL N407 1715 Country Subdivision Code X1 ID 1/3

Code identifying the country subdivision
SYNTAX: E0207, C0704

300925 SITUATIONAL RULE: Required when the address is not in the United
States of America, including its territories, or Canada, and the
country in N404 has administrative subdivisions such as but not
limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.

OD:
271B1_2120C_N407__BenefitRelatedEntityCountrySubdivisionCode

IMPLEMENTATION NAME: Benefit Related Entity Country Subdivision Code

CODE SOURCE 5: Countries, Currencies and Funds

300926 Use the country subdivision codes from Part 2 of ISO 3166.

338 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120C • PER
TECHNICAL REPORT • TYPE 3 SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION
ADMINISTRATIVE COMMUNICATIONS CONTACT 005010X279 • 271
SUBSCRIBER • 2120C
BENEFIT • PER ENTITY CONTACT INFORMATION
RELATED
PER

SEGMENT DETAIL
549
300
PER - SUBSCRIBER BENEFIT RELATED
ENTITY CONTACT INFORMATION
X12 Segment Name: Administrative Communications Contact
X12 Purpose: To identify a person or office to whom administrative communications should be
directed
X12 Syntax: 1. P0304
If either PER03 or PER04 is present, then the other is required.
2. P0506
If either PER05 or PER06 is present, then the other is required.
3. P0708
If either PER07 or PER08 is present, then the other is required.
Loop: 2120C — SUBSCRIBER BENEFIT RELATED ENTITY NAME

Segment Repeat: 3

Usage: SITUATIONAL

87
09
30 Situational Rule: Required when Contact Information exists and is available. If not required
by this implementation guide, do not send.

441
300 TR3 Notes: 1. Use this segment when needed to identify a contact name and/or
communications number for the entity identified. This segment allows
for three contact numbers to be listed. This segment is used when the
information source wishes to provide a contact for the entity identified
in loop 2120C NM1.

If telephone extension is sent, it should always be in the occurrence

of the communications number following the actual phone number.
See the example for an illustration.

702
300 2. If this segment is used, at a minimum either PER02 must be used or
PER03 and PER04 must be used. It is recommended that at least
PER02, PER03 and PER04 are sent if this segment is used.

706
300 3. When the communication number represents a telephone number in
the United States and other countries using the North American
Dialing Plan (for voice, data, fax, etc.), the communication number
should always include the area code and phone number using the
format AAABBBCCCC. Where AAA is the area code, BBB is the
telephone number prefix, and CCCC is the telephone number (e.g.
(534)224-2525 would be represented as 5342242525). The extension,
when applicable, should be included in the communication number
immediately after the telephone number.

486
300 TR3 Example: PER✽IC✽BILLING DEPT✽TE✽2128763654✽EX✽2104✽FX✽2128769304~

APRIL 2008 339

005010X279 • 271 • 2120C • PER ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION TECHNICAL REPORT • TYPE 3

DIAGRAM

PER01 366 PER02 93 PER03 365 PER04 364 PER05 365 PER06 364
Contact Name Comm Comm Comm Comm
PER ✽ Funct Code
✽ ✽
Number Qual
✽
Number
✽
Number Qual
✽
Number
M1 ID 2/2 O1 AN 1/60 X1 ID 2/2 X1 AN 1/256 X1 ID 2/2 X1 AN 1/256

PER07 365 PER08 364 PER09 443

Comm Comm Contact Inq
✽ ✽ ✽ ~
Number Qual Number Reference
X1 ID 2/2 X1 AN 1/256 O1 AN 1/20

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PER01 366 Contact Function Code M1 ID 2/2

Code identifying the major duty or responsibility of the person or group named

OD: 271B1_2120C_PER01__ContactFunctionCode

300457 Use this code to specify the type of person or group to which the
contact number applies.
CODE DEFINITION

IC Information Contact
SITUATIONAL PER02 93 Name O 1 AN 1/60
Free-form name

301087 SITUATIONAL RULE: Required when the name of the individual to contact
is not already defined or is different than the name within 2120C
NM1 segment and the name is available;
OR
Required when PER03 and PER04 are not present.
If not required by this implementation guide, may be provided at
sender’s discretion, but cannot be required by the receiver.

OD: 271B1_2120C_PER02__BenefitRelatedEntityContactName

IMPLEMENTATION NAME: Benefit Related Entity Contact Name

300989 Use this name for the individual’s name or group’s name to use
when contacting the individual or organization.

340 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120C • PER
TECHNICAL REPORT • TYPE 3 SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION

SITUATIONAL PER03 365 Communication Number Qualifier X1 ID 2/2

Code identifying the type of communication number
SYNTAX: P0304

300990 SITUATIONAL RULE: Required

when PER02 is not present or when a
communication number, e-mail or Web address is to be sent in
addition to the contact name. If not required by this implementation
guide, may be provided at sender’s discretion, but cannot be
required by the receiver.

OD: 271B1_2120C_PER03__CommunicationNumberQualifier

300459 Use this code to specify what type of communication number is

following.
CODE DEFINITION

ED Electronic Data Interchange Access Number

EM Electronic Mail
FX Facsimile
TE Telephone
UR Uniform Resource Locator (URL)
WP Work Phone Number
SITUATIONAL PER04 364 Communication Number X1 AN 1/256
Complete communications number including country or area code when
applicable
SYNTAX: P0304

300990 SITUATIONAL RULE: Required

when PER02 is not present or when a
communication number, e-mail or Web address is to be sent in
addition to the contact name. If not required by this implementation
guide, may be provided at sender’s discretion, but cannot be
required by the receiver.

OD:
271B1_2120C_PER04__BenefitRelatedEntityCommunicationNumber

IMPLEMENTATION NAME: Benefit Related Entity Communication Number

300514 The format for US domestic phone numbers is:

AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number

300991 Use this for the communication number or URL as qualified by the
preceding data element.

APRIL 2008 341

005010X279 • 271 • 2120C • PER ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL PER05 365 Communication Number Qualifier X1 ID 2/2

Code identifying the type of communication number
SYNTAX: P0506

300992 SITUATIONAL RULE: Required

when a second communication contact
number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD: 271B1_2120C_PER05__CommunicationNumberQualifier

300459 Use this code to specify what type of communication number is

following.
CODE DEFINITION

ED Electronic Data Interchange Access Number

EM Electronic Mail
EX Telephone Extension
FX Facsimile
TE Telephone
UR Uniform Resource Locator (URL)
WP Work Phone Number
SITUATIONAL PER06 364 Communication Number X1 AN 1/256
Complete communications number including country or area code when
applicable
SYNTAX: P0506

300992 SITUATIONAL RULE: Required

when a second communication contact
number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD:
271B1_2120C_PER06__BenefitRelatedEntityCommunicationNumber

IMPLEMENTATION NAME: Benefit Related Entity Communication Number

300514 The format for US domestic phone numbers is:

AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number

300991 Use this for the communication number or URL as qualified by the
preceding data element.

342 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120C • PER
TECHNICAL REPORT • TYPE 3 SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION

SITUATIONAL PER07 365 Communication Number Qualifier X1 ID 2/2

Code identifying the type of communication number
SYNTAX: P0708

300993 SITUATIONAL RULE: Required

when a third communication contact
number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD: 271B1_2120C_PER07__CommunicationNumberQualifier

300459 Use this code to specify what type of communication number is

following.
CODE DEFINITION

ED Electronic Data Interchange Access Number

EM Electronic Mail
EX Telephone Extension
FX Facsimile
TE Telephone
UR Uniform Resource Locator (URL)
WP Work Phone Number
SITUATIONAL PER08 364 Communication Number X1 AN 1/256
Complete communications number including country or area code when
applicable
SYNTAX: P0708

300993 SITUATIONAL RULE: Required when a third communication contact

number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD:
271B1_2120C_PER08__BenefitRelatedEntityCommunicationNumber

IMPLEMENTATION NAME: Benefit Related Entity Communication Number

300514 The format for US domestic phone numbers is:

AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number

300991 Use this for the communication number or URL as qualified by the
preceding data element.
NOT USED PER09 443 Contact Inquiry Reference O 1 AN 1/20

APRIL 2008 343

 005010X279 • 271 • 2120C • PRV ASC X12N • INSURANCE SUBCOMMITTEE
SUBSCRIBER BENEFIT RELATED PROVIDER INFORMATION TECHNICAL REPORT • TYPE 3
PROVIDER INFORMATION SUBSCRIBER
005010X279 • 271 • 2120C
BENEFIT • PRV PROVIDER INFORMATION
RELATED
PRV

SEGMENT DETAIL
550
300
PRV - SUBSCRIBER BENEFIT RELATED
PROVIDER INFORMATION
X12 Segment Name: Provider Information
X12 Purpose: To specify the identifying characteristics of a provider
X12 Syntax: 1. P0203
If either PRV02 or PRV03 is present, then the other is required.
Loop: 2120C — SUBSCRIBER BENEFIT RELATED ENTITY NAME

Segment Repeat: 1

Usage: SITUATIONAL

94
06
30 Situational Rule: Required when needed either to identify a provider’s role or associate a
specialty type related to the service identified in the 2110C loop. If not
required by this implementation guide, do not send.

745
300 TR3 Notes: 1. If identifying a type of specialty associated with the services identified
in loop 2110C, use code PXC in PRV02 and the appropriate code in
PRV03.

838
300 2. If there is a PRV segment in 2100B or 2100C, this PRV overrides it for
this occurrence of the 2110C loop.

033
301 TR3 Example: PRV✽PE✽PXC✽207Q00000X~

DIAGRAM

PRV01 1221 PRV02 128 PRV03 127 PRV04 156 PRV05 C035 PRV06 1223
Provider Reference Reference State or Provider Provider
PRV ✽ Code
✽
Ident Qual
✽
Ident
✽
Prov Code
✽
Spec. Inf.
✽
Org Code ~
M1 ID 1/3 X1 ID 2/3 X1 AN 1/50 O1 ID 2/2 O1 O1 ID 3/3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PRV01 1221 Provider Code M1 ID 1/3

Code identifying the type of provider

OD: 271B1_2120C_PRV01__ProviderCode

CODE DEFINITION

AD Admitting
AT Attending
BI Billing
CO Consulting
CV Covering
H Hospital
HH Home Health Care
LA Laboratory

344 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120C • PRV
TECHNICAL REPORT • TYPE 3 SUBSCRIBER BENEFIT RELATED PROVIDER INFORMATION

OT Other Physician
P1 Pharmacist
P2 Pharmacy
PC Primary Care Physician
PE Performing
R Rural Health Clinic
RF Referring
SB Submitting
SK Skilled Nursing Facility
SU Supervising
SITUATIONAL PRV02 128 Reference Identification Qualifier X1 ID 2/3
Code qualifying the Reference Identification
SYNTAX: P0203

300994 SITUATIONAL RULE: Required

when needed to identify a provider’s
specialty type related to the service identified in the 2110C loop. If
not required by this implementation guide, do not send.

OD: 271B1_2120C_PRV02__ReferenceIdentificationQualifier

CODE DEFINITION

PXC Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy
SITUATIONAL PRV03 127 Reference Identification X1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: P0203

300994 SITUATIONAL RULE: Required

when needed to identify a provider’s
specialty type related to the service identified in the 2110C loop. If
not required by this implementation guide, do not send.

OD: 271B1_2120C_PRV03__ProviderIdentifier

IMPLEMENTATION NAME: Provider Identifier

300489 Use this reference number as qualified by the preceding data

element (PRV02).
NOT USED PRV04 156 State or Province Code O1 ID 2/2
NOT USED PRV05 C035 PROVIDER SPECIALTY INFORMATION O1
NOT USED PRV06 1223 Provider Organization Code O1 ID 3/3

APRIL 2008 345

 005010X279 • 271 • 2110C • LE ASC X12N • INSURANCE SUBCOMMITTEE
LOOP TRAILER TECHNICAL REPORT • TYPE 3
LOOP TRAILER 005010X279
LOOP • 271 • 2110C • LE
TRAILER
LE

SEGMENT DETAIL
600
300
LE - LOOP TRAILER
X12 Segment Name: Loop Trailer
X12 Purpose: To indicate that the loop immediately preceding this segment is complete
X12 Semantic: 1. One loop may be nested contained within another loop, provided the inner
nested loop terminates before the other loop. When specified by the
standards setting body as mandatory, this segment in combination with
“LS”, must be used. It is not to be used if not specifically set forth for use.
The loop identifier in the loop header and trailer must be identical. The
value for the identifier is the loop ID of the required loop beginning
segment. The loop ID number is given on the transaction set diagram in the
appropriate ASC X12 version/release.
X12 Comments: 1. See Figures Appendix for an explanation of the use of the LE and LS
segments.
Loop: 2110C — SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 1

Usage: SITUATIONAL

95
09
30 Situational Rule: Required when Loop 2120C is used. If not required by this implementation
guide, do not send.

747
300 TR3 Notes: 1. Use this segment to identify the end of the Subscriber Benefit Related
Entity Name loop. Because both the subscriber’s name loop and this
loop begin with NM1 segments, the LS and LE segments are used to
differentiate these two loops.

801
300 TR3 Example: LE✽2120~

DIAGRAM

LE01 447
Loop ID
LE ✽ Code
M1 AN 1/4

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED LE01 447 Loop Identifier Code M 1 AN 1/4

The loop ID number given on the transaction set diagram is the value for this data
element in segments LS and LE

OD: 271B1_2110C_LE01__LoopIdentifierCode

300810 This data element must have the value of “2120".

346 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000D • HL
TECHNICAL REPORT • TYPE 3 DEPENDENT LEVEL
HIERARCHICAL LEVEL DEPENDENT• LEVEL
005010X279 271 • 2000D • HL
HL

SEGMENT DETAIL
515
300
HL - DEPENDENT LEVEL
X12 Segment Name: Hierarchical Level
X12 Purpose: To identify dependencies among and the content of hierarchically related
groups of data segments
X12 Comments: 1. The HL segment is used to identify levels of detail information using a
hierarchical structure, such as relating line-item data to shipment data, and
packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
Loop: 2000D — DEPENDENT LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: SITUATIONAL

96
09
30 Situational Rule: Required if the patient is a dependent who does not have a unique
Member Identification Number (See Section 1.4.2) unless the 271 response
contains an AAA segment in loop 2000A, 2100A, 2100B, 2100C or 2110C. If
not required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

879
300 TR3 Notes: 1. See Section 1.4.2 Basic Concepts for more information about
dependents and patients.

436
300 2. Use this segment to identify the hierarchical or entity level of
information being conveyed. The HL structure allows for the efficient
nesting of related occurrences of information. The developers’ intent
is to clearly identify the relationship of the patient to the subscriber
and the subscriber to the provider.

Additionally, multiple subscribers and/or dependents (i.e., the patient)

can be grouped together under the same provider or the information
for multiple providers or information receivers can be grouped
together for the same payer or information source. See Section 1.3.2
for limitations on the number of occurrences of patients.

APRIL 2008 347

005010X279 • 271 • 2000D • HL ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT LEVEL TECHNICAL REPORT • TYPE 3

069
301 3. An example of the overall structure of the transaction set when used
in batch mode is:

Information Source Loop 2000A

Information Receiver Loop 2000B
Subscriber Loop 2000C
Dependent Loop 2000D
Eligibility or Benefit Information
Subscriber Loop 2000C
Eligibility or Benefit Information
Dependent Loop 2000D
Eligibility or Benefit Information

The above example shows 2 different Subscribers. The first

Subscriber is not the patient, only the dependent is the patient. The
second Subscriber is a patient and the Dependent is also a patient.

695
300 TR3 Example: HL✽4✽3✽23✽0~

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736

Hierarch Hierarch Hierarch Hierarch
HL ✽ ID Number
✽
Parent ID
✽
Level Code
✽
Child Code
~
M1 AN 1/12 O1 AN 1/12 M1 ID 1/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HL01 628 Hierarchical ID Number M 1 AN 1/12

A unique number assigned by the sender to identify a particular data segment in
a hierarchical structure
COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence
of the HL segment in the transaction set. For example, HL01 could be used to
indicate the number of occurrences of the HL segment, in which case the value of
HL01 would be “1" for the initial HL segment and would be incremented by one in
each subsequent HL segment within the transaction.

OD: 271B1_2000D_HL01__HierarchicalIDNumber

300447 Use the sequentially assigned positive number to identify each

specific occurrence of an HL segment within a transaction set. The
first HL segment in the transaction should begin with the number
one and be incremented by one for each successive occurrence of
the HL segment within that specific transaction set (ST through SE).

348 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000D • HL
TECHNICAL REPORT • TYPE 3 DEPENDENT LEVEL

300748 An example of the use of the HL segment and this data element is:

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS***MD*SV*0202034~
HL*3*2*22*1~
NM1*IL*1*SMITH*ROBERT*B***MI*11122333301~
HL*4*3*23*0~
NM1*03*1*SMITH*MARY*LOU~
Eligibility/Benefit Data
HL*5*2*22*0~
NM1*IL*1*BROWN*JOHN*E***MI*22211333301~
Eligibility/Benefit Data
REQUIRED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12
Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which
the current HL segment is subordinate.

OD: 271B1_2000D_HL02__HierarchicalParentIDNumber

300907 Use this ID number to identify the specific Subscriber to which this
Dependent is subordinate.
REQUIRED HL03 735 Hierarchical Level Code M1 ID 1/2
Code defining the characteristic of a level in a hierarchical structure
COMMENT: HL03 indicates the context of the series of segments following the
current HL segment up to the next occurrence of an HL segment in the
transaction. For example, HL03 is used to indicate that subsequent segments in
the HL loop form a logical grouping of data referring to shipment, order, or item-
level information.

OD: 271B1_2000D_HL03__HierarchicalLevelCode

301083 All data that follows this HL segment is associated with the
Dependent identified by the level code. This association continues
until the next occurrence of an HL segment.
CODE DEFINITION

23 Dependent
300498 Use the dependent level to identify an individual(s)
who may be a dependent of the subscriber/insured.
This entity may or may not be the actual patient.

APRIL 2008 349

005010X279 • 271 • 2000D • HL ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT LEVEL TECHNICAL REPORT • TYPE 3

REQUIRED HL04 736 Hierarchical Child Code O1 ID 1/1

Code indicating if there are hierarchical child data segments subordinate to the
level being described
COMMENT: HL04 indicates whether or not there are subordinate (or child) HL
segments related to the current HL segment.

OD: 271B1_2000D_HL04__HierarchicalChildCode

300581 Because of the hierarchical structure, and because no subordinate

HL levels exist, the code value in the HL04 at the Loop 2000D level
must be “0" (zero).
CODE DEFINITION

0 No Subordinate HL Segment in This Hierarchical

Structure.

350 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000D • TRN
TECHNICAL REPORT • TYPE 3 DEPENDENT TRACE NUMBER
TRACE DEPENDENT• TRACE
005010X279 271 • 2000D • TRN
NUMBER
TRN

SEGMENT DETAIL
516
300
TRN - DEPENDENT TRACE NUMBER
X12 Segment Name: Trace
X12 Purpose: To uniquely identify a transaction to an application
X12 Set Notes: 1. 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.
Loop: 2000D — DEPENDENT LEVEL

Segment Repeat: 3

Usage: SITUATIONAL

97
09
30 Situational Rule: Required when the 270 request contained one or two TRN segments and
the dependent is the patient (See Section 1.4.2.). One TRN segment for
each TRN submitted in the 270 must be returned.;
OR
Required when the Information Source needs to return a unique trace
number for the current transaction.
If not required by this implementation guide, do not send.

812
300 TR3 Notes: 1. An information source may receive up to two TRN segments in each
loop 2000D of a 270 transaction and must return each of them in loop
2000D of the 271 transaction unless the person submitted in loop
2000D is determined to be a subscriber, then the TRN segments must
be returned in loop 2000C (See Section 1.4.2). The returned TRN
segments will have a value of “2” in TRN01. See Section 1.4.6
Information Linkage for additional information.

813
300 2. An information source may add one TRN segment to loop 2000D with
a value of “1" in TRN01 and must identify themselves in TRN03.

696
300 3. If this transaction passes through a clearinghouse, the clearinghouse
will receive from the information source the information receiver’s
TRN segment and the clearinghouse’s TRN segment with a value of
“2” in TRN01. Since the ultimate destination of the transaction is the
information receiver, if the clearinghouse intends on passing their
TRN segment to the information receiver, the clearinghouse must
change the value in TRN01 to “1” of their TRN segment. This must be
done since the trace number in the clearinghouse’s TRN segment is
not actually a referenced transaction trace number to the information
receiver.

052
301 4. The trace number in the 271 transaction TRN02 must be returned
exactly as submitted in the 270 transaction. For example, if the 270
transaction TRN02 was 012345678 it must be returned as 012345678
and not as 12345678.

APRIL 2008 351

005010X279 • 271 • 2000D • TRN ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT TRACE NUMBER TECHNICAL REPORT • TYPE 3

661
300 TR3 Example: TRN✽2✽98175-012547✽9877281234✽RADIOLOGY~
TRN✽2✽109834652831✽9XYZCLEARH✽REALTIME~
TRN✽1✽209991094361✽9ABCINSURE~

The above example represents how an information source would respond.

The first TRN segment was initiated by the information receiver. The
second TRN segment was initiated by the clearinghouse. The third TRN
segment was initiated by the information source.

703
300 TR3 Example: TRN✽2✽98175-012547✽9877281234✽RADIOLOGY~
TRN✽1✽109834652831✽9XYZCLEARH✽REALTIME~
TRN✽1✽209991094361✽9ABCINSURE~

The above example represents how a clearinghouse would respond to the

same set of TRN segments if the clearinghouse intends to pass their TRN
segment on to the information receiver. If the clearinghouse does not
intend to pass their TRN segment on to the information receiver, only the
first and third TRN segments in the example would be sent.

DIAGRAM

TRN01 481 TRN02 127 TRN03 509 TRN04 127

Trace Type Reference
✽ Originating ✽ Reference
TRN ✽ Code
✽
Ident Company ID Ident
~
M1 ID 1/2 M1 AN 1/50 O1 AN 10/10 O1 AN 1/50

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED TRN01 481 Trace Type Code M1 ID 1/2

Code identifying which transaction is being referenced

OD: 271B1_2000D_TRN01__TraceTypeCode

CODE DEFINITION

1 Current Transaction Trace Numbers

300697 The term “Current Transaction Trace Numbers”
refers to trace or reference numbers assigned by
the creator of the 271 transaction (the information
source).

If a clearinghouse has assigned a TRN segment and

intends on returning their TRN segment in the 271
response to the information receiver, they must
convert the value in TRN01 to “1" (since it will be
returned by the information source as a ”2").
2 Referenced Transaction Trace Numbers
300557 The term “Referenced Transaction Trace Numbers”
refers to trace or reference numbers originally sent
in the 270 transaction and now returned in the 271.

352 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2000D • TRN
TECHNICAL REPORT • TYPE 3 DEPENDENT TRACE NUMBER

REQUIRED TRN02 127 Reference Identification M 1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SEMANTIC: TRN02 provides unique identification for the transaction.

OD: 271B1_2000D_TRN02__TraceNumber

IMPLEMENTATION NAME: Trace Number

301053 This element must contain the trace number submitted in TRN02
from the 270 transaction and must be returned exactly as
submitted.
REQUIRED TRN03 509 Originating Company Identifier O 1 AN 10/10
A unique identifier designating the company initiating the funds transfer
instructions, business transaction or assigning tracking reference identification.
SEMANTIC: TRN03 identifies an organization.

OD: 271B1_2000D_TRN03__TraceAssigningEntityIdentifier

IMPLEMENTATION NAME: Trace Assigning Entity Identifier

300664 If TRN01 is “1”, use this information to identify the organization

that assigned this trace number.

301102 If TRN01 is “2", this is the value received in the original 270
transaction.

300665 The first position must be either a “1” if an EIN is used, a “3” if a
DUNS is used or a “9” if a user assigned identifier is used.
SITUATIONAL TRN04 127 Reference Identification O 1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SEMANTIC: TRN04 identifies a further subdivision within the organization.

300998 SITUATIONAL RULE: Required when TRN01 = “2" and this element was
used in the corresponding 270 TRN segment.;
OR
Required when TRN01 = ”1" and the Information Source needs to
further identify a specific component, such as a specific division or
group of the entity identified in the previous data element (TRN03).
If not required by this implementation guide, do not send.

OD: 271B1_2000D_TRN04__TraceAssigningEntityAdditionalIdentifier

IMPLEMENTATION NAME: Trace Assigning Entity Additional Identifier

300666 If TRN01 is “1", use this information if necessary to further identify

a specific component, such as a specific division or group of the
entity identified in the previous data element (TRN03).

300663 If TRN01 is “2”, this is the value received in the original 270
transaction.

APRIL 2008 353

 005010X279 • 271 • 2100D • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT NAME TECHNICAL REPORT • TYPE 3
INDIVIDUAL OR ORGANIZATIONAL NAME DEPENDENT• NAME
005010X279 271 • 2100D • NM1
NM1

SEGMENT DETAIL
517
300
NM1 - DEPENDENT NAME
X12 Segment Name: Individual or Organizational Name
X12 Purpose: To supply the full name of an individual or organizational entity
X12 Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
3. C1203
If NM112 is present, then NM103 is required.
Loop: 2100D — DEPENDENT NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

465
300 TR3 Notes: 1. Use this segment to identify an entity by name. This NM1 loop is used
to identify the dependent of an insured or subscriber.

625
300 TR3 Example: NM1✽03✽1✽SMITH✽JOHN✽L✽✽JR~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038
Entity ID Entity Type Name Last/ Name Name Name
NM1 ✽
Code
✽
Qualifier
✽
Org Name
✽
First
✽
Middle
✽
Prefix
M1 ID 2/3 M1 ID 1/1 X1 AN 1/60 O1 AN 1/35 O1 AN 1/25 O1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

Name ID Code ID Entity Entity ID Name Last/
✽ ✽ ✽ ✽ ✽ ✽ ~
Suffix Qualifier Code Relat Code Code Org Name
O1 AN 1/10 X1 ID 1/2 X1 AN 2/80 X1 ID 2/2 O1 ID 2/3 O1 AN 1/60

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED NM101 98 Entity Identifier Code M1 ID 2/3

Code identifying an organizational entity, a physical location, property or an
individual

OD: 271B1_2100D_NM101__EntityIdentifierCode

CODE DEFINITION

03 Dependent

354 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • NM1
TECHNICAL REPORT • TYPE 3 DEPENDENT NAME

REQUIRED NM102 1065 Entity Type Qualifier M1 ID 1/1

Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.

OD: 271B1_2100D_NM102__EntityTypeQualifier

CODE DEFINITION

1 Person
SITUATIONAL NM103 1035 Name Last or Organization Name X1 AN 1/60
Individual last name or organizational name
SYNTAX: C1203

300669 SITUATIONAL RULE: Required unless a rejection response is generated

and this element was not valued in the request.
If not required by this implementation guide, do not send.

OD: 271B1_2100D_NM103__DependentLastName

IMPLEMENTATION NAME: Dependent Last Name

300518 Use this name for the dependent’s last name.

SITUATIONAL NM104 1036 Name First O 1 AN 1/35

Individual first name

300669 SITUATIONAL RULE: Required unless a rejection response is generated

and this element was not valued in the request.
If not required by this implementation guide, do not send.

OD: 271B1_2100D_NM104__DependentFirstName

IMPLEMENTATION NAME: Dependent First Name

300519 Use this name for the dependent’s first name.

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25

Individual middle name or initial

301103 SITUATIONAL RULE: Requiredwhen the Information Source requires this

information to identify the Dependent for subsequent EDI
transactions (see Section 1.4.7) unless a rejection response is
generated and this element was not valued in the request. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100D_NM105__DependentMiddleName

IMPLEMENTATION NAME: Dependent Middle Name

300520 Use this name for the dependent’s middle name or initial.
NOT USED NM106 1038 Name Prefix O 1 AN 1/10

APRIL 2008 355

005010X279 • 271 • 2100D • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT NAME TECHNICAL REPORT • TYPE 3

SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10

Suffix to individual name

301103 SITUATIONAL RULE: Requiredwhen the Information Source requires this

information to identify the Dependent for subsequent EDI
transactions (see Section 1.4.7) unless a rejection response is
generated and this element was not valued in the request. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100D_NM107__DependentNameSuffix

IMPLEMENTATION NAME: Dependent Name Suffix

300452 Use this for the suffix to an individual’s name; e.g., Sr., Jr., or III.

NOT USED NM108 66 Identification Code Qualifier X1 ID 1/2

NOT USED NM109 67 Identification Code X1 AN 2/80
NOT USED NM110 706 Entity Relationship Code X1 ID 2/2
NOT USED NM111 98 Entity Identifier Code O1 ID 2/3
NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

356 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • REF
TECHNICAL REPORT • TYPE 3 DEPENDENT ADDITIONAL IDENTIFICATION
REFERENCE INFORMATION DEPENDENT• ADDITIONAL
005010X279 271 • 2100D •IDENTIFICATION
REF
REF

SEGMENT DETAIL
521
300
REF - DEPENDENT ADDITIONAL
IDENTIFICATION
X12 Segment Name: Reference Information
X12 Purpose: To specify identifying information
X12 Syntax: 1. R0203
At least one of REF02 or REF03 is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 9

Usage: SITUATIONAL

99
09
30 Situational Rule: Required when the Information Source requires additional identifiers
necessary to identify the Dependent for subsequent EDI transactions (see
Section 1.4.7);
OR
Required when the 270 request contained a REF segment with a Patient
Account Number in Loop 2100D/REF02 with REF01 equal EJ;
OR
Required when the 270 request contained a REF segment and the
information provided in that REF segment was used to locate the
individual in the information source’s system (See Section 1.4.7).
If not required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

802
300 TR3 Notes: 1. If the 270 request contained a REF segment with a Patient Account
Number in Loop 2100D/REF02 with REF01 equal EJ, then it must be
returned in the 271 transaction using this segment if the patient is the
Dependent. The Patient Account Number in the 271 transaction must
be returned exactly as submitted in the 270 transaction.

638
300 2. Use this segment to supply an identification number other than or in
addition to the Member Identification Number. The type of reference
number is determined by the qualifier in REF01. Only one occurrence
of each REF01 code value may be used in the 2100D loop.

639
300 3. Health Insurance Claim (HIC) Number or Medicaid Recipient
Identification Numbers are to be provided in the NM1 segment as a
Member Identification Number when it is the primary number an
information source knows a member by (such as for Medicare or
Medicaid). Do not use this segment for the Health Insurance Claim
(HIC) Number or Medicaid Recipient Identification Number unless they
are different from the Member Identification Number provided in the
NM1 segment.

492
300 TR3 Example: REF✽EJ✽660415~

618
300 TR3 Example: REF✽49✽03~

APRIL 2008 357

005010X279 • 271 • 2100D • REF ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

Reference Reference Description Reference
REF ✽ Ident Qual
✽
Ident
✽ ✽
Identifier
~
M1 ID 2/3 X1 AN 1/50 X1 AN 1/80 O1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED REF01 128 Reference Identification Qualifier M1 ID 2/3

Code qualifying the Reference Identification

OD: 271B1_2100D_REF01__ReferenceIdentificationQualifier

300454 Use this code to specify or qualify the type of reference number
that is following in REF02, REF03, or both.

301070 Only one occurrence of each REF01 code value may be used in the
2100D loop.
CODE DEFINITION

18 Plan Number
1L Group or Policy Number
300622 Use this code only if it cannot be determined if the
number is a Group Number or a Policy number. Use
codes “IG” or “6P” when they can be determined.
49 Family Unit Number
300943 Required when the Information Source is a
Pharmacy Benefit Manager (PBM) and the individual
has a suffix to their member ID number that is
required for use in the NCPDP Telecom Standard in
the Insurance Segment in field 303-C3 Person Code.
If not required by this implementation Guide, do not
send.

NOTE: For all other uses, the Family Unit Number

(suffix) is considered a part of the Member ID
number and is used to uniquely identify the
individual and must be returned at the end of the
Member ID number in 2100C NM109 or in 2100C
REF02 if REF01 is “1W”.
6P Group Number
CT Contract Number
300848 This code is to be used only to identify the
provider’s contract number of the provider identified
in the PRV segment of Loop 2100C. This code is
only to be used once the CMS National Provider
Identifier has been mandated for use, and must be
sent if required in the contract between the
Information Receiver identified in Loop 2100B and
the Information Source identified in Loop 2100A.
EA Medical Record Identification Number

358 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • REF
TECHNICAL REPORT • TYPE 3 DEPENDENT ADDITIONAL IDENTIFICATION

EJ Patient Account Number

F6 Health Insurance Claim (HIC) Number
300833 See segment note 3.
GH Identification Card Serial Number
300640 Use this code when the Identification Card has a
number in addition to the Member Identification
Number or Identity Card Number. The Identification
Card Serial Number uniquely identifies the card
when multiple cards have been or will be issued to a
member (e.g., on a monthly basis, replacement
cards). This is particularly prevalent in the Medicaid
environment.
HJ Identity Card Number
300641 Use this code when the Identity Card Number is
different than the Member Identification Number.
This is particularly prevalent in the Medicaid
environment.
IF Issue Number
IG Insurance Policy Number
MRC Eligibility Category
CODE SOURCE 844: Eligibility Category
N6 Plan Network Identification Number
NQ Medicaid Recipient Identification Number
300833 See segment note 3.
Q4 Prior Identifier Number
300619 This code is to be used when a corrected or new
identification number is returned in NM109, the
originally submitted identification number is to be
returned in REF02. To be used in conjunction with
code “001” in INS03 and code “25” in INS04.
SY Social Security Number
300658 The social security number may not be used for any
Federally administered programs such as Medicare.
Y4 Agency Claim Number
301000 This code is to only to be used when the information
source is a Property and Casualty payer. Use this
code to identify the Property and Casualty Claim
Number associated with the dependent. This code is
not a HIPAA requirement as of this writing.

APRIL 2008 359

005010X279 • 271 • 2100D • REF ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3

REQUIRED REF02 127 Reference Identification X1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: R0203

OD: 271B1_2100D_REF02__DependentSupplementalIdentifier

IMPLEMENTATION NAME: Dependent Supplemental Identifier

300453 Use this information for the reference number as qualified by the
preceding data element (REF01).

301056 If REF01 is “EJ”, the Patient Account Number from the 270
transaction must be returned exactly as submitted.
SITUATIONAL REF03 352 Description X1 AN 1/80
A free-form description to clarify the related data elements and their content
SYNTAX: R0203

300945 SITUATIONAL RULE: Required

when REF01 = “18", ”6P" or “N6" and a
name needs to be associated with the corresponding identifier. If
not required by this implementation guide, do not send.

OD: 271B1_2100D_REF03__PlanGrouporPlanNetworkName

IMPLEMENTATION NAME: Plan, Group or Plan Network Name

NOT USED REF04 C040 REFERENCE IDENTIFIER O1

360 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • N3
TECHNICAL REPORT • TYPE 3 DEPENDENT ADDRESS
PARTY LOCATION DEPENDENT• ADDRESS
005010X279 271 • 2100D • N3
N3

SEGMENT DETAIL
522
300
N3 - DEPENDENT ADDRESS
X12 Segment Name: Party Location
X12 Purpose: To specify the location of the named party
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

01
10
30 Situational Rule: Required when the Information Source requires this information to
identify the Dependent for subsequent EDI transactions (see Section
1.4.7), but not required if a rejection response is generated and this
segment was not sent in the request. If not required by this
implementation guide, may be provided at sender’s discretion but cannot
be required by the receiver.

674
300 TR3 Notes: 1. Do not return address information from the 270 request.

582
300 2. Use this segment to identify address information for a dependent.

493
300 TR3 Example: N3✽15197 BROADWAY AVENUE✽APT 215~

DIAGRAM

N301 166 N302 166

Address Address
N3 ✽
Information
✽
Information ~
M1 AN 1/55 O1 AN 1/55

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N301 166 Address Information M 1 AN 1/55

Address information

OD: 271B1_2100D_N301__DependentAddressLine

IMPLEMENTATION NAME: Dependent Address Line

300455 Use this information for the first line of the address information.

APRIL 2008 361

005010X279 • 271 • 2100D • N3 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ADDRESS TECHNICAL REPORT • TYPE 3

SITUATIONAL N302 166 Address Information O 1 AN 1/55

Address information

300946 SITUATIONAL RULE: Requiredwhen the Information Source requires this

information to identify the Subscriber for subsequent EDI
transactions (see Section 1.4.7) unless a rejection response is
generated. If not required by this implementation guide, may be
provided at sender’s discretion but cannot be required by the
receiver.

OD: 271B1_2100D_N302__DependentAddressLine

IMPLEMENTATION NAME: Dependent Address Line

300456 Use this information for the second line of the address information.

362 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • N4
TECHNICAL REPORT • TYPE 3 DEPENDENT CITY, STATE, ZIP CODE
GEOGRAPHIC LOCATION DEPENDENT• CITY,
005010X279 271 • STATE,
2100D •ZIP
N4 CODE
N4

SEGMENT DETAIL
523
300
N4 - DEPENDENT CITY, STATE, ZIP CODE
X12 Segment Name: Geographic Location
X12 Purpose: To specify the geographic place of the named party
X12 Syntax: 1. E0207
Only one of N402 or N407 may be present.
2. C0605
If N406 is present, then N405 is required.
3. C0704
If N407 is present, then N404 is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

01
10
30 Situational Rule: Required when the Information Source requires this information to
identify the Dependent for subsequent EDI transactions (see Section
1.4.7), but not required if a rejection response is generated and this
segment was not sent in the request. If not required by this
implementation guide, may be provided at sender’s discretion but cannot
be required by the receiver.

041
301 TR3 Notes: 1. Do not return address information from the 270 request.

042
301 2. Use this segment to identify address information for a dependent.

920
300 TR3 Example: N4✽KANSAS CITY✽MO✽64108~

DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310
City State or Postal Country Location Location
N4 ✽ Name
✽
Prov Code
✽
Code
✽
Code
✽
Qualifier
✽
Identifier
O1 AN 2/30 X1 ID 2/2 O1 ID 3/15 X1 ID 2/3 X1 ID 1/2 O1 AN 1/30

N407 1715

✽ Country Sub ~
Code
X1 ID 1/3

APRIL 2008 363

005010X279 • 271 • 2100D • N4 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N401 19 City Name O 1 AN 2/30

Free-form text for city name
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.

OD: 271B1_2100D_N401__DependentCityName

IMPLEMENTATION NAME: Dependent City Name

SITUATIONAL N402 156 State or Province Code X1 ID 2/2
Code (Standard State/Province) as defined by appropriate government agency
SYNTAX: E0207
COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

300921 SITUATIONAL RULE: Required

when the address is in the United States of
America, including its territories, or Canada. If not required by this
implementation guide, do not send.

OD: 271B1_2100D_N402__DependentStateCode

IMPLEMENTATION NAME: Dependent State Code

CODE SOURCE 22: States and Provinces

SITUATIONAL N403 116 Postal Code O1 ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)

300922 SITUATIONAL RULE: Requiredwhen the address is in the United States of

America, including its territories, or Canada, or when a postal code
exists for the country in N404. If not required by this
implementation guide, do not send.

OD: 271B1_2100D_N403__DependentPostalZoneorZIPCode

IMPLEMENTATION NAME: Dependent Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes
SITUATIONAL N404 26 Country Code X1 ID 2/3
Code identifying the country
SYNTAX: C0704

300923 SITUATIONAL RULE: Required

when the address is outside the United
States of America. If not required by this implementation guide, do
not send.

OD: 271B1_2100D_N404__DependentCountryCode

IMPLEMENTATION NAME: Dependent Country Code

CODE SOURCE 5: Countries, Currencies and Funds

300924 Use the alpha-2 country codes from Part 1 of ISO 3166.

NOT USED N405 309 Location Qualifier X1 ID 1/2

NOT USED N406 310 Location Identifier O 1 AN 1/30

364 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • N4
TECHNICAL REPORT • TYPE 3 DEPENDENT CITY, STATE, ZIP CODE

SITUATIONAL N407 1715 Country Subdivision Code X1 ID 1/3

Code identifying the country subdivision
SYNTAX: E0207, C0704

300925 SITUATIONAL RULE: Required

when the address is not in the United
States of America, including its territories, or Canada, and the
country in N404 has administrative subdivisions such as but not
limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.

OD: 271B1_2100D_N407__DependentCountrySubdivisionCode

IMPLEMENTATION NAME: Dependent Country Subdivision Code

CODE SOURCE 5: Countries, Currencies and Funds

300926 Use the country subdivision codes from Part 2 of ISO 3166.

APRIL 2008 365

 005010X279 • 271 • 2100D • AAA ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT REQUEST VALIDATION TECHNICAL REPORT • TYPE 3
REQUEST VALIDATION DEPENDENT• REQUEST
005010X279 271 • 2100D • AAA
VALIDATION
AAA

SEGMENT DETAIL
601
300
AAA - DEPENDENT REQUEST VALIDATION
X12 Segment Name: Request Validation
X12 Purpose: To specify the validity of the request and indicate follow-up action authorized
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 9

Usage: SITUATIONAL

52
07
30 Situational Rule: Required when the request could not be processed at a system or
application level when specifically related to the data contained in the
original 270 transaction’s dependent name loop (Loop 2100D) and to
indicate what action the originator of the request transaction should take.
If not required by this implementation guide, do not send.

753
300 TR3 Notes: 1. Use this segment to indicate problems in processing the transaction
specifically related to the data contained in the original 270
transaction’s dependent name loop (Loop 2100D).

071
301 TR3 Example: AAA✽N✽✽58✽C~

DIAGRAM

AAA01 1073 AAA02 559 AAA03 901 AAA04 889

✽ Yes/No Cond ✽ Agency Reject Follow-up

AAA Resp Code Qual Code
✽
Reason Code
✽
Act Code ~
M1 ID 1/1 O1 ID 2/2 O1 ID 2/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED AAA01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: AAA01 designates whether the request is valid or invalid. Code “Y”
indicates that the code is valid; code “N” indicates that the code is invalid.

OD: 271B1_2100D_AAA01__ValidRequestIndicator

IMPLEMENTATION NAME: Valid Request Indicator

CODE DEFINITION

N No
Y Yes
NOT USED AAA02 559 Agency Qualifier Code O1 ID 2/2

366 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • AAA
TECHNICAL REPORT • TYPE 3 DEPENDENT REQUEST VALIDATION

REQUIRED AAA03 901 Reject Reason Code O1 ID 2/2

Code assigned by issuer to identify reason for rejection

OD: 271B1_2100D_AAA03__RejectReasonCode

300438 Use this code for the reason why the transaction was unable to be
processed successfully. This may indicate problems with the
system, the application, or the data content.

300628 Use codes “43", ”45", “47", ”48", or “51" only in response to
information that is in or should be in the PRV segment in the
Dependent Name loop (2100D).
CODE DEFINITION

15 Required application data missing

35 Out of Network
300909 Use this code to indicate that the dependent is not
in the Network of the provider identified in the 2100B
NM1 segment, or the 2100B/2100D PRV segment if
present, in the 270 transaction.
42 Unable to Respond at Current Time
300583 Use this code in a batch environment where an
information source returns all requests from the 270
in the 271 and identifies “Unable to Respond at
Current Time” for each individual request
(subscriber or dependent) within the transaction
that they were unable to process for reasons other
than data content (such as their system is down or
timed out in generating a response). Use only codes
“R”, “S”, or “Y” for AAA04.
43 Invalid/Missing Provider Identification
45 Invalid/Missing Provider Specialty
47 Invalid/Missing Provider State
48 Invalid/Missing Referring Provider Identification
Number
49 Provider is Not Primary Care Physician
51 Provider Not on File
52 Service Dates Not Within Provider Plan Enrollment
56 Inappropriate Date
57 Invalid/Missing Date(s) of Service
58 Invalid/Missing Date-of-Birth
301003 Code 58 may not be returned if the information
source has located an individual and the Birth Date
does not match; use code 71 instead.
60 Date of Birth Follows Date(s) of Service
61 Date of Death Precedes Date(s) of Service
62 Date of Service Not Within Allowable Inquiry Period
63 Date of Service in Future
64 Invalid/Missing Patient ID

APRIL 2008 367

005010X279 • 271 • 2100D • AAA ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT REQUEST VALIDATION TECHNICAL REPORT • TYPE 3

65 Invalid/Missing Patient Name

300952 Required when the transaction was rejected when
the information source cannot find a match for the
Patient Name submitted or if the Patient Name was
missing.
66 Invalid/Missing Patient Gender Code
67 Patient Not Found
301079 Code 67 may not be returned if the information
receiver submitted all four pieces of the mandated
search option.
68 Duplicate Patient ID Number
71 Patient Birth Date Does Not Match That for the
Patient on the Database
300950 Code 71 must be returned when the transaction was
rejected when the information source located an
individual based other information submitted, but
the Birth Date does not match.
77 Subscriber Found, Patient Not Found
REQUIRED AAA04 889 Follow-up Action Code O1 ID 1/1
Code identifying follow-up actions allowed

OD: 271B1_2100D_AAA04__FollowupActionCode

300437 Use this code to instruct the recipient of the 271 about what action
needs to be taken, if any, based on the validity code and the reject
reason code (if applicable).
CODE DEFINITION

C Please Correct and Resubmit

N Resubmission Not Allowed
R Resubmission Allowed
300577 Use only when AAA03 is “42".
S Do Not Resubmit; Inquiry Initiated to a Third Party
W Please Wait 30 Days and Resubmit
X Please Wait 10 Days and Resubmit
Y Do Not Resubmit; We Will Hold Your Request and
Respond Again Shortly
300577 Use only when AAA03 is “42".

368 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • PRV
TECHNICAL REPORT • TYPE 3 PROVIDER INFORMATION
PROVIDER INFORMATION • 271 • 2100D • PRV
005010X279INFORMATION
PROVIDER
PRV

SEGMENT DETAIL
e
Non
PRV - PROVIDER INFORMATION
X12 Segment Name: Provider Information
X12 Purpose: To specify the identifying characteristics of a provider
X12 Syntax: 1. P0203
If either PRV02 or PRV03 is present, then the other is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

39
08
30 Situational Rule: Required when the 270 request contained a 2100D PRV segment and the
information contained in the PRV segment was used to determine the 271
response.;
OR
Required when needed either to identify a specific provider or to associate
a specialty type related to the service identified in the 2110D loop. This
PRV segment applies to all benefits in this 2100D loop unless overridden
by a PRV segment in the 2120D loop.
If not required by this implementation guide, do not send.

743
300 TR3 Notes: 1. If identifying a specific provider, use this segment to convey specific
information about a provider’s role in the eligibility/benefit being
inquired about when the provider is not the information receiver. For
example, if the information receiver is a hospital and a referring
provider must be identified, this is the segment where the referring
provider would be identified.

744
300 2. If identifying a specific provider, this segment contains reference
identification numbers, all of which may be used up until the time the
National Provider Identifier (NPI) is mandated for use. After the NPI is
mandated, only the code for National Provider Identifier may be used.

762
300 3. If identifying a type of specialty associated with the services identified
in loop 2110D, use code PXC in PRV02 and the appropriate code in
PRV03.

763
300 4. PRV02 qualifies PRV03.

840
300 5. If there is a PRV segment in 2100B, this PRV overrides it for this
occurrence of the 2100D loop.

050
301 TR3 Example: PRV✽RF✽PXC✽207Q00000X~

DIAGRAM

PRV01 1221 PRV02 128 PRV03 127 PRV04 156 PRV05 C035 PRV06 1223
Provider Reference Reference State or Provider Provider
PRV ✽
Code
✽
Ident Qual
✽
Ident
✽
Prov Code
✽
Spec. Inf.
✽
Org Code ~
M1 ID 1/3 X1 ID 2/3 X1 AN 1/50 O1 ID 2/2 O1 O1 ID 3/3

APRIL 2008 369

005010X279 • 271 • 2100D • PRV ASC X12N • INSURANCE SUBCOMMITTEE
PROVIDER INFORMATION TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PRV01 1221 Provider Code M1 ID 1/3

Code identifying the type of provider

OD: 271B1_2100D_PRV01__ProviderCode

CODE DEFINITION

AD Admitting
AT Attending
BI Billing
CO Consulting
CV Covering
H Hospital
HH Home Health Care
LA Laboratory
OT Other Physician
P1 Pharmacist
P2 Pharmacy
PC Primary Care Physician
PE Performing
R Rural Health Clinic
SK Skilled Nursing Facility
SU Supervising
SITUATIONAL PRV02 128 Reference Identification Qualifier X1 ID 2/3
Code qualifying the Reference Identification
SYNTAX: P0203

300954 SITUATIONAL RULE: Requiredwhen needed to identify a provider’s

specialty type. If not required by this implementation guide, do not
send.

OD: 271B1_2100D_PRV02__ReferenceIdentificationQualifier

300828 If this segment is used to identify a type of specialty associated

with the services identified in loop 2110D, use code PXC.
CODE DEFINITION

PXC Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy

370 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • PRV
TECHNICAL REPORT • TYPE 3 PROVIDER INFORMATION

SITUATIONAL PRV03 127 Reference Identification X1 AN 1/50

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: P0203

300954 SITUATIONAL RULE: Requiredwhen needed to identify a provider’s

specialty type. If not required by this implementation guide, do not
send.

OD: 271B1_2100D_PRV03__ProviderIdentifier

IMPLEMENTATION NAME: Provider Identifier

300817 Use this number for the reference number as qualified by the
preceding data element (PRV02).
NOT USED PRV04 156 State or Province Code O1 ID 2/2
NOT USED PRV05 C035 PROVIDER SPECIALTY INFORMATION O1
NOT USED PRV06 1223 Provider Organization Code O1 ID 3/3

APRIL 2008 371

 005010X279 • 271 • 2100D • DMG ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT DEMOGRAPHIC INFORMATION TECHNICAL REPORT • TYPE 3
DEMOGRAPHIC INFORMATION DEPENDENT• DEMOGRAPHIC
005010X279 271 • 2100D • DMG
INFORMATION
DMG

SEGMENT DETAIL
541
300
DMG - DEPENDENT DEMOGRAPHIC
INFORMATION
X12 Segment Name: Demographic Information
X12 Purpose: To supply demographic information
X12 Syntax: 1. P0102
If either DMG01 or DMG02 is present, then the other is required.
2. P1011
If either DMG10 or DMG11 is present, then the other is required.
3. C1105
If DMG11 is present, then DMG05 is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

04
10
30 Situational Rule: Required when the Dependent is the patient unless a rejection response is
generated with a 2100D or 2110D AAA segment and this segment was not
sent in the request. If not required by this implementation guide, may be
provided at sender’s discretion but cannot be required by the receiver.

584
300 TR3 Notes: 1. Use this segment to convey the birth date or gender demographic
information for the dependent.

626
300 TR3 Example: DMG✽D8✽19750616✽M~

DIAGRAM

DMG01 1250 DMG02 1251 DMG03 1068 DMG04 1067 DMG05 C056 DMG06 1066

✽ Date Time ✽ Date Time Gender Marital Comp Race

✽ Citizenship
DMG Format Qual Period
✽
Code
✽
Status Code
✽
or Ethn Inf Status Code
X1 ID 2/3 X1 AN 1/35 O1 ID 1/1 O1 ID 1/1 X 10 O1 ID 1/2

DMG07 26 DMG08 659 DMG09 380 DMG10 1270 DMG11 1271

Country Basis of Quantity Code List Industry
✽ ✽ ✽ ✽ ✽ ~
Code Verif Code Qual Code Code
O1 ID 2/3 O1 ID 1/2 O1 R 1/15 X1 ID 1/3 X1 AN 1/30

372 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • DMG
TECHNICAL REPORT • TYPE 3 DEPENDENT DEMOGRAPHIC INFORMATION

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

SITUATIONAL DMG01 1250 Date Time Period Format Qualifier X1 ID 2/3

Code indicating the date format, time format, or date and time format
SYNTAX: P0102

301072 SITUATIONAL RULE: Required when Dependent Birth Date is sent in

DMG02. If not required by this implementation guide, do not send.

OD: 271B1_2100D_DMG01__DateTimePeriodFormatQualifier

300467 Use this code to indicate the format of the date of birth that follows
in DMG02.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

SITUATIONAL DMG02 1251 Date Time Period X1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times
SYNTAX: P0102
SEMANTIC: DMG02 is the date of birth.

301002 SITUATIONAL RULE: Required

when the Dependent is the patient unless a
rejection response is generated with a 2100D or 2110D AAA
segment and this element was not sent in the request. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100D_DMG02__DependentBirthDate

IMPLEMENTATION NAME: Dependent Birth Date

301073 Use this date for the date of birth of the dependent.
SITUATIONAL DMG03 1068 Gender Code O1 ID 1/1
Code indicating the sex of the individual

301002 SITUATIONAL RULE: Required

when the Dependent is the patient unless a
rejection response is generated with a 2100D or 2110D AAA
segment and this element was not sent in the request. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100D_DMG03__DependentGenderCode

IMPLEMENTATION NAME: Dependent Gender Code

CODE DEFINITION

F Female
M Male
U Unknown
NOT USED DMG04 1067 Marital Status Code O1 ID 1/1
NOT USED DMG05 C056 COMPOSITE RACE OR ETHNICITY X
INFORMATION 10
NOT USED DMG06 1066 Citizenship Status Code O1 ID 1/2

APRIL 2008 373

005010X279 • 271 • 2100D • DMG ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT DEMOGRAPHIC INFORMATION TECHNICAL REPORT • TYPE 3

NOT USED DMG07 26 Country Code O1 ID 2/3

NOT USED DMG08 659 Basis of Verification Code O1 ID 1/2
NOT USED DMG09 380 Quantity O1 R 1/15
NOT USED DMG10 1270 Code List Qualifier Code X1 ID 1/3
NOT USED DMG11 1271 Industry Code X1 AN 1/30

374 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • INS
TECHNICAL REPORT • TYPE 3 DEPENDENT RELATIONSHIP
INSURED BENEFIT DEPENDENT• RELATIONSHIP
005010X279 271 • 2100D • INS
INS

SEGMENT DETAIL
602
300
INS - DEPENDENT RELATIONSHIP
X12 Segment Name: Insured Benefit
X12 Purpose: To provide benefit information on insured entities
X12 Syntax: 1. P1112
If either INS11 or INS12 is present, then the other is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

04
10
30 Situational Rule: Required when the Dependent is the patient unless a rejection response is
generated with a 2100D or 2110D AAA segment and this segment was not
sent in the request. If not required by this implementation guide, may be
provided at sender’s discretion but cannot be required by the receiver.

768
300 TR3 Notes: 1. This segment may also be used to identify that the information source
has changed some of the identifying elements for the dependent that
the information receiver submitted in the original 270 transaction.

558
300 TR3 Example: INS✽N✽19✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽3~

DIAGRAM

INS01 1073 INS02 1069 INS03 875 INS04 1203 INS05 1216 INS06 C052

✽ Yes/No Cond ✽ Individual

✽ Maintenance ✽ Maintain Benefit
✽ Medicare
INS Resp Code Relat Code Type Code Reason Code
✽
Status Code Status Code
M1 ID 1/1 M1 ID 2/2 O1 ID 3/3 O1 ID 2/3 O1 ID 1/1 O1

INS07 1219 INS08 584 INS09 1220 INS10 1073 INS11 1250 INS12 1251

✽ COBRA Qual ✽ Employment ✽ Student

✽ Yes/No Cond ✽ Date Time ✽ Date Time
Event Code Status Code Status Code Resp Code Format Qual Period
O1 ID 1/2 O1 ID 2/2 O1 ID 1/1 O1 ID 1/1 X1 ID 2/3 X1 AN 1/35

INS13 1165 INS14 19 INS15 156 INS16 26 INS17 1470

Confident City State or Country Number
✽ ✽ ✽ ✽ ✽ ~
Code Name Prov Code Code
O1 ID 1/1 O1 AN 2/30 O1 ID 2/2 O1 ID 2/3 O1 N0 1/9

APRIL 2008 375

005010X279 • 271 • 2100D • INS ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT RELATIONSHIP TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED INS01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: INS01 indicates status of the insured. A “Y” value indicates the insured
is a subscriber: an “N” value indicates the insured is a dependent.

OD: 271B1_2100D_INS01__InsuredIndicator

IMPLEMENTATION NAME: Insured Indicator

CODE DEFINITION

N No
REQUIRED INS02 1069 Individual Relationship Code M1 ID 2/2
Code indicating the relationship between two individuals or entities

OD: 271B1_2100D_INS02__IndividualRelationshipCode

CODE DEFINITION

01 Spouse
19 Child
20 Employee
21 Unknown
300698 Use this code only if relationship information is not
available and there is a need to use data elements
INS03, INS04, or INS17.
39 Organ Donor
40 Cadaver Donor
53 Life Partner
G8 Other Relationship
SITUATIONAL INS03 875 Maintenance Type Code O1 ID 3/3
Code identifying the specific type of item maintenance

301005 SITUATIONAL RULE: Requiredalong with INS04 when acknowledging a

change in the identifying elements for the dependent from those
submitted in the 270. If not required by this implementation guide,
do not send.

OD: 271B1_2100D_INS03__MaintenanceTypeCode

301006 Use this element (and code “25" in INS04) if any of the identifying
elements for the dependent have been changed from those
submitted in the 270.
CODE DEFINITION

001 Change

376 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • INS
TECHNICAL REPORT • TYPE 3 DEPENDENT RELATIONSHIP

SITUATIONAL INS04 1203 Maintenance Reason Code O1 ID 2/3

Code identifying the reason for the maintenance change

301007 SITUATIONAL RULE: Requiredalong with INS03 when acknowledging a

change in the identifying elements for the dependent from those
submitted in the 270. If not required by this implementation guide,
do not send.

OD: 271B1_2100D_INS04__MaintenanceReasonCode

301008 Use this element (and code “001" in INS03) if any of the identifying
elements for the dependent have been changed from those
submitted in the 270.
CODE DEFINITION

25 Change in Identifying Data Elements

300585 Use this code to indicate that a change has been
made to the primary elements that identify a specific
person. Such elements are first name, last name,
date of birth, and identification numbers.
NOT USED INS05 1216 Benefit Status Code O1 ID 1/1
NOT USED INS06 C052 MEDICARE STATUS CODE O1
NOT USED INS07 1219 Consolidated Omnibus Budget Reconciliation O1 ID 1/2
Act (COBRA) Qualifying
NOT USED INS08 584 Employment Status Code O1 ID 2/2
NOT USED INS09 1220 Student Status Code O1 ID 1/1
NOT USED INS10 1073 Yes/No Condition or Response Code O1 ID 1/1
NOT USED INS11 1250 Date Time Period Format Qualifier X1 ID 2/3
NOT USED INS12 1251 Date Time Period X1 AN 1/35
NOT USED INS13 1165 Confidentiality Code O1 ID 1/1
NOT USED INS14 19 City Name O 1 AN 2/30
NOT USED INS15 156 State or Province Code O1 ID 2/2
NOT USED INS16 26 Country Code O1 ID 2/3
SITUATIONAL INS17 1470 Number O1 N0 1/9
A generic number
SEMANTIC: INS17 is the number assigned to each family member born with the
same birth date. This number identifies birth sequence for multiple births allowing
proper tracking and response of benefits for each dependent (i.e., twins, triplets,
etc.).

301009 SITUATIONAL RULE: Required when the Birth Sequence Number

submitted in the 270 was used to locate the Dependent. If not
required by this implementation guide, may be provided at sender’s
discretion but cannot be required by the receiver.

OD: 271B1_2100D_INS17__BirthSequenceNumber

IMPLEMENTATION NAME: Birth Sequence Number

300642 Use to indicate the birth order in the event of multiple births in
association with the birth date supplied in DMG02.

APRIL 2008 377

 005010X279 • 271 • 2100D • HI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3
HEALTH CARE INFORMATION CODES DEPENDENT• HEALTH
005010X279 271 • 2100D
CARE• HI
DIAGNOSIS CODE
HI

SEGMENT DETAIL
910
300
HI - DEPENDENT HEALTH CARE DIAGNOSIS
CODE
X12 Segment Name: Health Care Information Codes
X12 Purpose: To supply information related to the delivery of health care
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

12
09
30 Situational Rule: Required when an HI segment was received in the 270 and if the
information source uses the information in the determination of the
eligibility or benefit response for the dependent. All information used from
the HI segment of the 270 used in the determination of the eligibility or
benefit response for the dependent must be returned. If information was
provided in an HI segment of 270 but was not used in the determination of
the eligibility or benefits for the dependent it must not be returned. The
information source must not use information in an HI segment of the 270
transaction in the determination of eligibility or benefits for the dependent
if that information cannot be returned in the 271 response.
OR
Required when needed to identify limitations in the benefits identified in
the 2110D loops, such as if benefits are limited for a specific diagnosis
code if the information source can support this high level functionality. If
the information source cannot support this high level functionality, do not
send.

913
300 TR3 Notes: 1. Use the Diagnosis code pointers in 2110D EB14 to identify which
diagnosis code or codes in this HI segment relates to the information
provided in the EB segment.

896
300 2. Do not transmit the decimal points in the diagnosis codes. The
decimal point is assumed.

911
300 TR3 Example: HI✽BK:8901✽BF:87200✽BF:5559~

DIAGRAM

HI01 C022 HI02 C022 HI03 C022 HI04 C022 HI05 C022 HI06 C022

✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care
HI Code Info. Code Info. Code Info. Code Info. Code Info. Code Info.
M1 O1 O1 O1 O1 O1

HI07 C022 HI08 C022 HI09 C022 HI10 C022 HI11 C022 HI12 C022

✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ~
Code Info. Code Info. Code Info. Code Info. Code Info. Code Info.
O1 O1 O1 O1 O1 O1

378 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • HI
TECHNICAL REPORT • TYPE 3 DEPENDENT HEALTH CARE DIAGNOSIS CODE

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED HI01 C022 HEALTH CARE CODE INFORMATION M1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

OD: 271B1_2100D_HI01_C022

300897 E codes are Not Used in HI01 except when defined by the claims
processor. E codes may be put in any other HI element using BF as
the qualifier.

300898 The diagnosis listed in this element is assumed to be the principal

diagnosis.
REQUIRED HI01 - 1 1270 Code List Qualifier Code M ID 1/3
Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100D_HI01_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABK International Classification of Diseases Clinical

Modification (ICD-10-CM) Principal Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BK International Classification of Diseases Clinical
Modification (ICD-9-CM) Principal Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI01 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100D_HI01_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI01 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI01 - 4 1251 Date Time Period X AN 1/35
NOT USED HI01 - 5 782 Monetary Amount O R 1/18
NOT USED HI01 - 6 380 Quantity O R 1/15
NOT USED HI01 - 7 799 Version Identifier O AN 1/30
NOT USED HI01 - 8 1271 Industry Code X AN 1/30
NOT USED HI01 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 379

005010X279 • 271 • 2100D • HI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI02 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

301058 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data element has been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100D_HI02_C022

REQUIRED HI02 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100D_HI02_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI02 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100D_HI02_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI02 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI02 - 4 1251 Date Time Period X AN 1/35
NOT USED HI02 - 5 782 Monetary Amount O R 1/18
NOT USED HI02 - 6 380 Quantity O R 1/15
NOT USED HI02 - 7 799 Version Identifier O AN 1/30
NOT USED HI02 - 8 1271 Industry Code X AN 1/30
NOT USED HI02 - 9 1073 Yes/No Condition or Response Code X ID 1/1

380 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • HI
TECHNICAL REPORT • TYPE 3 DEPENDENT HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI03 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100D_HI03_C022

REQUIRED HI03 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100D_HI03_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI03 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100D_HI03_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI03 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI03 - 4 1251 Date Time Period X AN 1/35
NOT USED HI03 - 5 782 Monetary Amount O R 1/18
NOT USED HI03 - 6 380 Quantity O R 1/15
NOT USED HI03 - 7 799 Version Identifier O AN 1/30
NOT USED HI03 - 8 1271 Industry Code X AN 1/30
NOT USED HI03 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 381

005010X279 • 271 • 2100D • HI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI04 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100D_HI04_C022

REQUIRED HI04 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100D_HI04_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI04 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100D_HI04_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI04 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI04 - 4 1251 Date Time Period X AN 1/35
NOT USED HI04 - 5 782 Monetary Amount O R 1/18
NOT USED HI04 - 6 380 Quantity O R 1/15
NOT USED HI04 - 7 799 Version Identifier O AN 1/30
NOT USED HI04 - 8 1271 Industry Code X AN 1/30
NOT USED HI04 - 9 1073 Yes/No Condition or Response Code X ID 1/1

382 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • HI
TECHNICAL REPORT • TYPE 3 DEPENDENT HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI05 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100D_HI05_C022

REQUIRED HI05 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100D_HI05_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI05 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100D_HI05_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI05 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI05 - 4 1251 Date Time Period X AN 1/35
NOT USED HI05 - 5 782 Monetary Amount O R 1/18
NOT USED HI05 - 6 380 Quantity O R 1/15
NOT USED HI05 - 7 799 Version Identifier O AN 1/30
NOT USED HI05 - 8 1271 Industry Code X AN 1/30
NOT USED HI05 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 383

005010X279 • 271 • 2100D • HI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI06 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100D_HI06_C022

REQUIRED HI06 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100D_HI06_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI06 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100D_HI06_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI06 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI06 - 4 1251 Date Time Period X AN 1/35
NOT USED HI06 - 5 782 Monetary Amount O R 1/18
NOT USED HI06 - 6 380 Quantity O R 1/15
NOT USED HI06 - 7 799 Version Identifier O AN 1/30
NOT USED HI06 - 8 1271 Industry Code X AN 1/30
NOT USED HI06 - 9 1073 Yes/No Condition or Response Code X ID 1/1

384 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • HI
TECHNICAL REPORT • TYPE 3 DEPENDENT HEALTH CARE DIAGNOSIS CODE

SITUATIONAL HI07 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100D_HI07_C022

REQUIRED HI07 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100D_HI07_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI07 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100D_HI07_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI07 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI07 - 4 1251 Date Time Period X AN 1/35
NOT USED HI07 - 5 782 Monetary Amount O R 1/18
NOT USED HI07 - 6 380 Quantity O R 1/15
NOT USED HI07 - 7 799 Version Identifier O AN 1/30
NOT USED HI07 - 8 1271 Industry Code X AN 1/30
NOT USED HI07 - 9 1073 Yes/No Condition or Response Code X ID 1/1

APRIL 2008 385

005010X279 • 271 • 2100D • HI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT HEALTH CARE DIAGNOSIS CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL HI08 C022 HEALTH CARE CODE INFORMATION O1

To send health care codes and their associated dates, amounts and quantities
SYNTAX:
P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

300899 SITUATIONAL RULE: Required

when it is necessary to report an additional
diagnosis and the preceding HI data elements have been used to
report other diagnoses. If not required by this implementation
guide, do not send.

OD: 271B1_2100D_HI08_C022

REQUIRED HI08 - 1 1270 Code List Qualifier Code M ID 1/3

Code identifying a specific industry code list
SEMANTIC:
C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

OD: 271B1_2100D_HI08_C02201_DiagnosisTypeCode

IMPLEMENTATION NAME: Diagnosis Type Code

CODE DEFINITION

ABF International Classification of Diseases Clinical

Modification (ICD-10-CM) Diagnosis
CODE SOURCE 897: International Classification of Diseases, 10th
Revision, Clinical Modification (ICD-10-CM)
BF International Classification of Diseases Clinical
Modification (ICD-9-CM) Diagnosis
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
REQUIRED HI08 - 2 1271 Industry Code M AN 1/30
Code indicating a code from a specific industry code list
SEMANTIC:
If C022-08 is used, then C022-02 represents the beginning value in a
range of codes.

OD: 271B1_2100D_HI08_C02202_DiagnosisCode

IMPLEMENTATION NAME: Diagnosis Code

NOT USED HI08 - 3 1250 Date Time Period Format Qualifier X ID 2/3
NOT USED HI08 - 4 1251 Date Time Period X AN 1/35
NOT USED HI08 - 5 782 Monetary Amount O R 1/18
NOT USED HI08 - 6 380 Quantity O R 1/15
NOT USED HI08 - 7 799 Version Identifier O AN 1/30
NOT USED HI08 - 8 1271 Industry Code X AN 1/30
NOT USED HI08 - 9 1073 Yes/No Condition or Response Code X ID 1/1
NOT USED HI09 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI10 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI11 C022 HEALTH CARE CODE INFORMATION O1
NOT USED HI12 C022 HEALTH CARE CODE INFORMATION O1

386 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • DTP
TECHNICAL REPORT • TYPE 3 DEPENDENT DATE
DATE OR TIME OR PERIOD DEPENDENT• DATE
005010X279 271 • 2100D • DTP
DTP

SEGMENT DETAIL
603
300
DTP - DEPENDENT DATE
X12 Segment Name: Date or Time or Period
X12 Purpose: To specify any or all of a date, a time, or a time period
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 9

Usage: SITUATIONAL

10
30 Situational Rule: Required to identify the Plan (DTP01 = 291) or Plan Begin (DTP01 = 346)
date when the individual has active coverage unless multiple plans apply
to the individual or multiple plan periods apply, which must then be
returned in the 2110D DTP (See Section 1.4.7);
OR
Required when needed to identify other relevant dates that apply to the
Dependent.
If not required by this implementation guide, do not send.

461
300 TR3 Notes: 1. The dates represented may be in the past, the current date, or a future
date. The dates may also be a single date or a span of dates. Which
date(s) to use is determined by the format qualifier in DTP02.

011
301 2. Dates supplied in the 2100D DTP apply to the Dependent and all
2110D loops unless overridden by an occurrence of a 2110D DTP with
the same value in DTP01.

494
300 TR3 Example: DTP✽346✽D8✽19950818~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251

Date/Time
✽ Date Time ✽ Date Time
DTP ✽ Qualifier Format Qual Period ~
M1 ID 3/3 M1 ID 2/3 M1 AN 1/35

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED DTP01 374 Date/Time Qualifier M1 ID 3/3

Code specifying type of date or time, or both date and time

OD: 271B1_2100D_DTP01__DateTimeQualifier

IMPLEMENTATION NAME: Date Time Qualifier

CODE DEFINITION

096 Discharge
102 Issue
152 Effective Date of Change
291 Plan

APRIL 2008 387

005010X279 • 271 • 2100D • DTP ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT DATE TECHNICAL REPORT • TYPE 3

307 Eligibility
318 Added
301059 Information Sources are encouraged to return
Added date in the case of retroactive eligibility.
340 Consolidated Omnibus Budget Reconciliation Act
(COBRA) Begin
341 Consolidated Omnibus Budget Reconciliation Act
(COBRA) End
342 Premium Paid to Date Begin
343 Premium Paid to Date End
346 Plan Begin
347 Plan End
356 Eligibility Begin
357 Eligibility End
382 Enrollment
435 Admission
442 Date of Death
458 Certification
472 Service
539 Policy Effective
540 Policy Expiration
636 Date of Last Update
771 Status
REQUIRED DTP02 1250 Date Time Period Format Qualifier M1 ID 2/3
Code indicating the date format, time format, or date and time format
SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

OD: 271B1_2100D_DTP02__DateTimePeriodFormatQualifier

300463 Use this code to specify the format of the date(s)/time(s) that follow
in the next data element.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

RD8 Range of Dates Expressed in Format CCYYMMDD-
CCYYMMDD
REQUIRED DTP03 1251 Date Time Period M 1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times

OD: 271B1_2100D_DTP03__DateTimePeriod

300462 Use this date for the date(s) as qualified by the preceding data
elements.

388 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • MPI
TECHNICAL REPORT • TYPE 3 DEPENDENT MILITARY PERSONNEL INFORMATION
MILITARY PERSONNEL INFORMATION DEPENDENT• MILITARY
005010X279 271 • 2100D • MPI
PERSONNEL INFORMATION
MPI

SEGMENT DETAIL
043
301
MPI - DEPENDENT MILITARY PERSONNEL
INFORMATION
X12 Segment Name: Military Personnel Information
X12 Purpose: To report military service data
X12 Syntax: 1. P0607
If either MPI06 or MPI07 is present, then the other is required.
Loop: 2100D — DEPENDENT NAME

Segment Repeat: 1

Usage: SITUATIONAL

44
10
30 Situational Rule: Required when this transaction is processed by DOD or
CHAMPUS/TRICARE and when necessary to convey the Dependent’s
military service data If not required by this implementation guide, do not
send.

086
301 TR3 Example: MPI✽C✽AO✽A✽✽L3~
Current Active Military - Overseas Air Force Lieutenant Colonel

DIAGRAM

MPI01 1201 MPI02 584 MPI03 1595 MPI04 352 MPI05 1596 MPI06 1250

✽ Information ✽ Employment ✽ Gov. Serv. Description Mil. Serv.

✽ Date Time
MPI Status Code Status Code Affil. Code
✽ ✽
Rank Code Format Qual
M1 ID 1/1 M1 ID 2/2 M1 ID 1/1 O1 AN 1/80 O1 ID 2/2 X1 ID 2/3

MPI07 1251
Date Time
✽ ~
Period
X1 AN 1/35

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED MPI01 1201 Information Status Code M1 ID 1/1

A code to indicate the status of information

OD: 271B1_2100D_MPI01__InformationStatusCode

CODE DEFINITION

A Partial
C Current
L Latest
O Oldest
P Prior
S Second Most Current
T Third Most Current

APRIL 2008 389

005010X279 • 271 • 2100D • MPI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT MILITARY PERSONNEL INFORMATION TECHNICAL REPORT • TYPE 3

REQUIRED MPI02 584 Employment Status Code M1 ID 2/2

Code showing the general employment status of an employee/claimant

OD: 271B1_2100D_MPI02__EmploymentStatusCode

CODE DEFINITION

AE Active Reserve
AO Active Military - Overseas
AS Academy Student
AT Presidential Appointee
AU Active Military - USA
CC Contractor
DD Dishonorably Discharged
HD Honorably Discharged
IR Inactive Reserves
LX Leave of Absence: Military
PE Plan to Enlist
RE Recommissioned
RM Retired Military - Overseas
RR Retired Without Recall
RU Retired Military - USA
REQUIRED MPI03 1595 Government Service Affiliation Code M1 ID 1/1
Code specifying the government service affiliation

OD: 271B1_2100D_MPI03__GovernmentServiceAffiliationCode

CODE DEFINITION

A Air Force
B Air Force Reserves
C Army
D Army Reserves
E Coast Guard
F Marine Corps
G Marine Corps Reserves
H National Guard
I Navy
J Navy Reserves
K Other
L Peace Corp
M Regular Armed Forces
N Reserves
O U.S. Public Health Service
Q Foreign Military
R American Red Cross
S Department of Defense
U United Services Organization
W Military Sealift Command

390 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2100D • MPI
TECHNICAL REPORT • TYPE 3 DEPENDENT MILITARY PERSONNEL INFORMATION

SITUATIONAL MPI04 352 Description O 1 AN 1/80

A free-form description to clarify the related data elements and their content
SEMANTIC: MPI04 is the actual response to further identify the exact military unit.

300962 SITUATIONAL RULE: Required when needed to further identify the exact
military unit. If not required by this implementation guide, do not
send.

OD: 271B1_2100D_MPI04__Description

SITUATIONAL MPI05 1596 Military Service Rank Code O1 ID 2/2

Code specifying the military service rank

300963 SITUATIONAL RULE: Required

when needed to indicate the current or
most recent military service rank. If not required by this
implementation guide, do not send.

OD: 271B1_2100D_MPI05__MilitaryServiceRankCode

CODE DEFINITION

A1 Admiral
A2 Airman
A3 Airman First Class
B1 Basic Airman
B2 Brigadier General
C1 Captain
C2 Chief Master Sergeant
C3 Chief Petty Officer
C4 Chief Warrant
C5 Colonel
C6 Commander
C7 Commodore
C8 Corporal
C9 Corporal Specialist 4
E1 Ensign
F1 First Lieutenant
F2 First Sergeant
F3 First Sergeant-Master Sergeant
F4 Fleet Admiral
G1 General
G4 Gunnery Sergeant
L1 Lance Corporal
L2 Lieutenant
L3 Lieutenant Colonel
L4 Lieutenant Commander
L5 Lieutenant General
L6 Lieutenant Junior Grade
M1 Major
M2 Major General
M3 Master Chief Petty Officer

APRIL 2008 391

005010X279 • 271 • 2100D • MPI ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT MILITARY PERSONNEL INFORMATION TECHNICAL REPORT • TYPE 3

M4 Master Gunnery Sergeant Major

M5 Master Sergeant
M6 Master Sergeant Specialist 8
P1 Petty Officer First Class
P2 Petty Officer Second Class
P3 Petty Officer Third Class
P4 Private
P5 Private First Class
R1 Rear Admiral
R2 Recruit
S1 Seaman
S2 Seaman Apprentice
S3 Seaman Recruit
S4 Second Lieutenant
S5 Senior Chief Petty Officer
S6 Senior Master Sergeant
S7 Sergeant
S8 Sergeant First Class Specialist 7
S9 Sergeant Major Specialist 9
SA Sergeant Specialist 5
SB Staff Sergeant
SC Staff Sergeant Specialist 6
T1 Technical Sergeant
V1 Vice Admiral
W1 Warrant Officer
SITUATIONAL MPI06 1250 Date Time Period Format Qualifier X1 ID 2/3
Code indicating the date format, time format, or date and time format
SYNTAX: P0607

300964 SITUATIONAL RULE: Required

when needed to indicate the beginning
date or date span of military service. If not required by this
implementation guide, do not send.

OD: 271B1_2100D_MPI06__DateTimePeriodFormatQualifier

CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

RD8 Range of Dates Expressed in Format CCYYMMDD-
CCYYMMDD
SITUATIONAL MPI07 1251 Date Time Period X1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times
SYNTAX: P0607
SEMANTIC: MPI07 indicates the date span of military service.

300964 SITUATIONAL RULE: Required

when needed to indicate the beginning
date or date span of military service. If not required by this
implementation guide, do not send.

OD: 271B1_2100D_MPI07__DateTimePeriod

392 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • EB
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION
ELIGIBILITY OR BENEFIT INFORMATION DEPENDENT• ELIGIBILITY
005010X279 271 • 2110DOR
• EB
BENEFIT INFORMATION
EB

SEGMENT DETAIL
606
300
EB - DEPENDENT ELIGIBILITY OR BENEFIT
INFORMATION
X12 Segment Name: Eligibility or Benefit Information
X12 Purpose: To supply eligibility or benefit information
X12 Syntax: 1. P0910
If either EB09 or EB10 is present, then the other is required.
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION Loop
Repeat: >1

Segment Repeat: 1

Usage: SITUATIONAL

45
10
30 Situational Rule: Required when the dependent is the person whose eligibility or benefits
are being described and the transaction is not rejected (see Section
1.4.10) or if the transaction needs to be rejected in this loop. If not
required by this implementation guide, do not send.

819
300 TR3 Notes: 1. See Section 1.4.7 Implementation-Compliant Use of the 270/271
Transaction Set for information about what information must be
returned if the subscriber is the person whose eligibility or benefits
are being sent.

854
300 2. Either EB03 or EB13 may be used in the same EB segment, not both.

829
300 3. EB03 is a repeating data element that may be repeated up to 99 times.
If all of the information that will be used in the 2110D loop is the same
with the exception of the Service Type Code used in EB03, it is more
efficient to use the repetition function of EB03 to send each of the
Service Type Codes needed. If an Information Source supports
responses with multiple Service Type Codes, the repetition use of
EB03 must be supported if all other elements in the 2110D loop are
identical.

679
300 4. A limit to the number of repeats of EB loops has not been established.
In a batch environment there is no practical reason to limit the number
of EB loop repeats. In a real time environment, consideration should
be given to how many EB loops are generated given the amount of
time it takes to format the response and the amount of time it will take
to transmit that response. Since these limitations will vary by
information source, it would be completely arbitrary for the
developers to set a limit. It is not the intent of the developers to limit
the amount of information that is returned in a response, rather to
alert information sources to consider the potential delays if the
response contains too much information to be formatted and
transmitted in real time.

468
300 5. Use this segment to begin the eligibility/benefit information looping
structure. The EB segment is used to convey the specific eligibility or
benefit information for the entity identified.

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495
300 TR3 Example: EB✽1✽FAM✽96✽GP~
Active Coverage for subscriber and family, for Professional (Physician)
services, and coverage is through a Group Policy

509
300 TR3 Example: EB✽B✽✽68✽✽✽27✽10~
Co-payment for Well Baby Care is $10 per visit

510
300 TR3 Example: EB✽C✽FAM✽✽✽✽23✽600~
Deductible for the family is $600 per calendar year

511
300 TR3 Example: EB✽L~
Primary Care Provider (information about the Primary Care Provider will
be located in the 2120 loop)

677
300 TR3 Example: EB✽A✽✽A6✽✽✽✽✽.50~
Co-Insurance is 50 percent for Psychotherapy

821
300 TR3 Example: EB✽B✽✽98^34^44^81^A0^A3✽✽✽✽10✽✽VS✽1~
Co-payment for Professional (Physician) Visit - Office, Chiropractic Office
Visits, Home Health Visits, Routine Physical, Professional (Physician)
Visit - Outpatient, Professional (Physician) Visit - Home, is $10 for one visit

DIAGRAM

EB01 1390 EB02 1207 EB03 1365 EB04 1336 EB05 1204 EB06 615
Eligibility Coverage Service Insurance Plan Cvrg
✽ Time Period
EB ✽ Benefit Inf
✽
Level Code
✽
Type Code
✽
Type Code
✽
Description Qualifier
M1 ID 1/2 O1 ID 3/3 O 99 ID 1/2 O1 ID 1/3 O1 AN 1/50 O1 ID 1/2

EB07 782 EB08 954 EB09 673 EB10 380 EB11 1073 EB12 1073
Monetary Percent Quantity Quantity
✽ ✽ ✽ ✽ ✽ Yes/No Cond ✽ Yes/No Cond
Amount Qualifier Resp Code Resp Code
O1 R 1/18 O1 R 1/10 X1 ID 2/2 X1 R 1/15 O1 ID 1/1 O1 ID 1/1

EB13 C003 EB14 C004

Comp. Med.
✽ ✽ Comp. Diag. ~
Proced. ID Code Point.
O1 O1

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ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED EB01 1390 Eligibility or Benefit Information Code M1 ID 1/2

Code identifying eligibility or benefit information
SEMANTIC: EB01 qualifies EB06 through EB10.

OD: 271B1_2110D_EB01__EligibilityorBenefitInformation

IMPLEMENTATION NAME: Eligibility or Benefit Information

300469 Use this code to identify the eligibility or benefit information. This
may be the eligibility status of the individual or the benefit related
category that is being further described in the following data
elements. This data element also qualifies the data in elements
EB06 through EB10.

300845 If codes A, B, C, G, J or Y are used, it is required that the patient’s

portion of responsibility is reflected in either EB07 or EB08. See
Section 1.4.9 Patient Responsibility for detailed information and
definitions.
CODE DEFINITION

1 Active Coverage
2 Active - Full Risk Capitation
3 Active - Services Capitated
4 Active - Services Capitated to Primary Care
Physician
5 Active - Pending Investigation
6 Inactive
7 Inactive - Pending Eligibility Update
8 Inactive - Pending Investigation
A Co-Insurance
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
B Co-Payment
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
C Deductible
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
CB Coverage Basis
D Benefit Description
E Exclusions
F Limitations
G Out of Pocket (Stop Loss)
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
H Unlimited
I Non-Covered

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J Cost Containment
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
K Reserve
L Primary Care Provider
M Pre-existing Condition
MC Managed Care Coordinator
N Services Restricted to Following Provider
O Not Deemed a Medical Necessity
P Benefit Disclaimer
300680 Not recommended. See section 1.4.11 Disclaimers
Within the Transaction.
Q Second Surgical Opinion Required
R Other or Additional Payor
S Prior Year(s) History
T Card(s) Reported Lost/Stolen
300822 Code “T” is typically used by Medicaids to indicate
to a provider that the person who has presented the
ID card is using a stolen ID card.
U Contact Following Entity for Eligibility or Benefit
Information
V Cannot Process
W Other Source of Data
X Health Care Facility
Y Spend Down
300846 See Section 1.4.9 Patient Responsibility for detailed
information and definitions.
SITUATIONAL EB02 1207 Coverage Level Code O1 ID 3/3
Code indicating the level of coverage being provided for this insured

301012 SITUATIONAL RULE: Requiredwhen needed to identify the types of

individuals associated with the eligibility or benefits being
identified in the 2110D loop. If not required by this implementation
guide, do not send.

OD: 271B1_2110D_EB02__BenefitCoverageLevelCode

IMPLEMENTATION NAME: Benefit Coverage Level Code

300965 This element is used in conjunction with EB01 codes (e.g. Active
Family Coverage, Deductible Individual, etc.). This element can be
used to identify types of individual’s within the Subscriber’s family
that eligibility or benefits extends to (unless EB01 = E - Exclusions).
CODE DEFINITION

CHD Children Only

DEP Dependents Only
ECH Employee and Children
ESP Employee and Spouse
FAM Family

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IND Individual
SPC Spouse and Children
SPO Spouse Only
SITUATIONAL EB03 1365 Service Type Code O ID 1/2
99
Code identifying the classification of service
SEMANTIC: Position of data in the repeating data element conveys no significance.

301013 SITUATIONAL RULE: Requiredwhen the dependent is the patient and has
been found in the Information Source’s system to identify Active or
Inactive Health Benefit Plan Coverage (See Section 1.4.7);
OR
Required when one of the Service Type Codes identified in Section
1.4.7 must be returned;
OR
Required when responding to a corresponding Service Type code
used from the 270 transaction;
OR
Required when the eligibility or benefits being identified in the
2110D loop need to be associated with a specific Service Type
Code.
If not required by this implementation guide or if EB13 is used, do
not send.

OD: 271B1_2110D_EB03__ServiceTypeCode

300900 See Section 1.4.7 Implementation-Compliant Use of the 270/271

Transaction Set for information about what service type codes
must be returned.

300841 EB03 is a repeating data element that may be repeated up to 99

times. If all of the information that will be used in the 2110D loop is
the same with the exception of the Service Type Code used in
EB03, it is more efficient to use the repetition function of EB03 to
send each of the Service Type Codes needed. If an Information
Source supports responses with multiple Service Type Codes, the
repetition use of EB03 must be supported if all other elements in
the 2110D loop are identical.

300855 Not used if EB13 is present.

CODE DEFINITION

1 Medical Care
2 Surgical
3 Consultation
4 Diagnostic X-Ray
5 Diagnostic Lab
6 Radiation Therapy
7 Anesthesia
8 Surgical Assistance
9 Other Medical
10 Blood Charges
11 Used Durable Medical Equipment
12 Durable Medical Equipment Purchase

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13 Ambulatory Service Center Facility

14 Renal Supplies in the Home
15 Alternate Method Dialysis
16 Chronic Renal Disease (CRD) Equipment
17 Pre-Admission Testing
18 Durable Medical Equipment Rental
19 Pneumonia Vaccine
20 Second Surgical Opinion
21 Third Surgical Opinion
22 Social Work
23 Diagnostic Dental
24 Periodontics
25 Restorative
26 Endodontics
27 Maxillofacial Prosthetics
28 Adjunctive Dental Services
30 Health Benefit Plan Coverage
301060 See Section 1.4.7.1
32 Plan Waiting Period
33 Chiropractic
34 Chiropractic Office Visits
35 Dental Care
36 Dental Crowns
37 Dental Accident
38 Orthodontics
39 Prosthodontics
40 Oral Surgery
41 Routine (Preventive) Dental
42 Home Health Care
43 Home Health Prescriptions
44 Home Health Visits
45 Hospice
46 Respite Care
47 Hospital
48 Hospital - Inpatient
49 Hospital - Room and Board
50 Hospital - Outpatient
51 Hospital - Emergency Accident
52 Hospital - Emergency Medical
53 Hospital - Ambulatory Surgical
54 Long Term Care
55 Major Medical
56 Medically Related Transportation
57 Air Transportation

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58 Cabulance
59 Licensed Ambulance
60 General Benefits
61 In-vitro Fertilization
62 MRI/CAT Scan
63 Donor Procedures
64 Acupuncture
65 Newborn Care
66 Pathology
67 Smoking Cessation
68 Well Baby Care
69 Maternity
70 Transplants
71 Audiology Exam
72 Inhalation Therapy
73 Diagnostic Medical
74 Private Duty Nursing
75 Prosthetic Device
76 Dialysis
77 Otological Exam
78 Chemotherapy
79 Allergy Testing
80 Immunizations
81 Routine Physical
82 Family Planning
83 Infertility
84 Abortion
85 AIDS
86 Emergency Services
87 Cancer
88 Pharmacy
89 Free Standing Prescription Drug
90 Mail Order Prescription Drug
91 Brand Name Prescription Drug
92 Generic Prescription Drug
93 Podiatry
94 Podiatry - Office Visits
95 Podiatry - Nursing Home Visits
96 Professional (Physician)
97 Anesthesiologist
98 Professional (Physician) Visit - Office
99 Professional (Physician) Visit - Inpatient
A0 Professional (Physician) Visit - Outpatient
A1 Professional (Physician) Visit - Nursing Home

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A2 Professional (Physician) Visit - Skilled Nursing

Facility
A3 Professional (Physician) Visit - Home
A4 Psychiatric
A5 Psychiatric - Room and Board
A6 Psychotherapy
A7 Psychiatric - Inpatient
A8 Psychiatric - Outpatient
A9 Rehabilitation
AA Rehabilitation - Room and Board
AB Rehabilitation - Inpatient
AC Rehabilitation - Outpatient
AD Occupational Therapy
AE Physical Medicine
AF Speech Therapy
AG Skilled Nursing Care
AH Skilled Nursing Care - Room and Board
AI Substance Abuse
AJ Alcoholism
AK Drug Addiction
AL Vision (Optometry)
AM Frames
AN Routine Exam
300856 Use for Routine Vision Exam only.
AO Lenses
AQ Nonmedically Necessary Physical
AR Experimental Drug Therapy
B1 Burn Care
B2 Brand Name Prescription Drug - Formulary
B3 Brand Name Prescription Drug - Non-Formulary
BA Independent Medical Evaluation
BB Partial Hospitalization (Psychiatric)
BC Day Care (Psychiatric)
BD Cognitive Therapy
BE Massage Therapy
BF Pulmonary Rehabilitation
BG Cardiac Rehabilitation
BH Pediatric
BI Nursery
BJ Skin
BK Orthopedic
BL Cardiac
BM Lymphatic
BN Gastrointestinal

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BP Endocrine
BQ Neurology
BR Eye
BS Invasive Procedures
BT Gynecological
BU Obstetrical
BV Obstetrical/Gynecological
BW Mail Order Prescription Drug: Brand Name
BX Mail Order Prescription Drug: Generic
BY Physician Visit - Office: Sick
BZ Physician Visit - Office: Well
C1 Coronary Care
CA Private Duty Nursing - Inpatient
CB Private Duty Nursing - Home
CC Surgical Benefits - Professional (Physician)
CD Surgical Benefits - Facility
CE Mental Health Provider - Inpatient
CF Mental Health Provider - Outpatient
CG Mental Health Facility - Inpatient
CH Mental Health Facility - Outpatient
CI Substance Abuse Facility - Inpatient
CJ Substance Abuse Facility - Outpatient
CK Screening X-ray
CL Screening laboratory
CM Mammogram, High Risk Patient
CN Mammogram, Low Risk Patient
CO Flu Vaccination
CP Eyewear and Eyewear Accessories
CQ Case Management
DG Dermatology
DM Durable Medical Equipment
DS Diabetic Supplies
GF Generic Prescription Drug - Formulary
GN Generic Prescription Drug - Non-Formulary
GY Allergy
IC Intensive Care
MH Mental Health
NI Neonatal Intensive Care
ON Oncology
PT Physical Therapy
PU Pulmonary
RN Renal
RT Residential Psychiatric Treatment
TC Transitional Care

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TN Transitional Nursery Care

UC Urgent Care
SITUATIONAL EB04 1336 Insurance Type Code O1 ID 1/3
Code identifying the type of insurance policy within a specific insurance program

301104 SITUATIONAL RULE: Required when the Information Source requires the
Dependent’s Insurance Type Code for subsequent EDI transactions
(see Section 1.4.7). If not required by this implementation guide,
may be provided at sender’s discretion but cannot be required by
the receiver.

OD: 271B1_2110D_EB04__InsuranceTypeCode

CODE DEFINITION

12 Medicare Secondary Working Aged Beneficiary or

Spouse with Employer Group Health Plan
13 Medicare Secondary End-Stage Renal Disease
Beneficiary in the Mandated Coordination Period
with an Employer’s Group Health Plan
14 Medicare Secondary, No-fault Insurance including
Auto is Primary
15 Medicare Secondary Worker’s Compensation
16 Medicare Secondary Public Health Service (PHS)or
Other Federal Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veteran’s Administration
43 Medicare Secondary Disabled Beneficiary Under
Age 65 with Large Group Health Plan (LGHP)
47 Medicare Secondary, Other Liability Insurance is
Primary
AP Auto Insurance Policy
C1 Commercial
CO Consolidated Omnibus Budget Reconciliation Act
(COBRA)
CP Medicare Conditionally Primary
D Disability
DB Disability Benefits
EP Exclusive Provider Organization
FF Family or Friends
GP Group Policy
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) - Medicare
Risk
HS Special Low Income Medicare Beneficiary
IN Indemnity
IP Individual Policy
LC Long Term Care
LD Long Term Policy
LI Life Insurance

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LT Litigation
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
OT Other
301061 When this code is returned by Medicare or a
Medicare Part D administrator, this code indicates a
type of insurance of Medicare Part D.
PE Property Insurance - Personal
PL Personal
PP Personal Payment (Cash - No Insurance)
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare Beneficiary
RP Property Insurance - Real
SP Supplemental Policy
TF Tax Equity Fiscal Responsibility Act (TEFRA)
WC Workers Compensation
WU Wrap Up Policy
SITUATIONAL EB05 1204 Plan Coverage Description O 1 AN 1/50
A description or number that identifies the plan or coverage

301014 SITUATIONAL RULE: Required

when a specific Plan Name exists for the
plan which the individual has coverage in conjunction with the
2110D loop with EB01 Status = 1, 2, 3, 4, 5, 6, 7 or 8 and EB03
Service Type Code = 30 (See Section 1.4.7). If not required by this
implementation guide, may be provided at sender’s discretion but
cannot be required by the receiver.

OD: 271B1_2110D_EB05__PlanCoverageDescription

300849 This element is to be used only to convey the specific product

name for an insurance plan. For example, if a plan has a brand
name, such as “Gold 1-2-3", the name may be placed in this
element. This element must not to be used to give benefit details of
a plan.

SITUATIONAL EB06 615 Time Period Qualifier O1 ID 1/2

Code defining periods

300754 SITUATIONAL RULE: Required when the availability of the eligibility or

benefits being identified in the 2110D loop need to be qualified by a
time period. If not required by this implementation guide, do not
send.

OD: 271B1_2110D_EB06__TimePeriodQualifier

CODE DEFINITION

6 Hour
7 Day

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13 24 Hours
21 Years
22 Service Year
23 Calendar Year
24 Year to Date
25 Contract
26 Episode
27 Visit
28 Outlier
29 Remaining
30 Exceeded
31 Not Exceeded
32 Lifetime
33 Lifetime Remaining
34 Month
35 Week
36 Admission
SITUATIONAL EB07 782 Monetary Amount O1 R 1/18
Monetary amount

300852 SITUATIONAL RULE: Required

when EB01 = B, C, G, J or Y. Do not use if
EB01 = A. May be used at the sender’s discretion for other EB01
values. May not be a negative number.

OD: 271B1_2110D_EB07__BenefitAmount

IMPLEMENTATION NAME: Benefit Amount

300473 Use this monetary amount as qualified by EB01.

300969 When EB01 = B, C, G, J or Y, the amount represents the Patient’s

portion of responsibility. See Section 1.4.9 Patient Responsibility.

300652 Use if eligibility or benefit must be qualified by a monetary amount;

e.g., deductible, co-payment.
SITUATIONAL EB08 954 Percentage as Decimal O1 R 1/10
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through
100%)

300853 SITUATIONAL RULE: Required when EB01 = A. Do not use if EB01 = B, C,

G, J or Y. May be used at the sender’s discretion for other EB01
values. May not be a negative number.

OD: 271B1_2110D_EB08__BenefitPercent

IMPLEMENTATION NAME: Benefit Percent

300474 Use this percentage rate as qualified by EB01.

300970 When EB01 = A, the amount represents the Patient’s portion of

responsibility. See Section 1.4.9 Patient Responsibility.

300653 Use if eligibility or benefit must be qualified by a percentage; e.g.,

co-insurance.

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SITUATIONAL EB09 673 Quantity Qualifier X1 ID 2/2

Code specifying the type of quantity
SYNTAX: P0910

301015 SITUATIONAL RULE: Required when needed to further qualify the

eligibility or benefits being identified in the 2110D loop by quantity.
If not required by this implementation guide, do not send.

OD: 271B1_2110D_EB09__QuantityQualifier

300472 Use this code to identify the type of units that are being conveyed
in the following data element (EB10).
CODE DEFINITION

8H Minimum
99 Quantity Used
CA Covered - Actual
CE Covered - Estimated
D3 Number of Co-insurance Days
DB Deductible Blood Units
DY Days
HS Hours
LA Life-time Reserve - Actual
LE Life-time Reserve - Estimated
M2 Maximum
MN Month
P6 Number of Services or Procedures
QA Quantity Approved
S7 Age, High Value
300616 Use this code when a benefit is based on a
maximum age for the patient.
S8 Age, Low Value
300617 Use this code when a benefit is based on a minimum
age for the patient.
VS Visits
YY Years
SITUATIONAL EB10 380 Quantity X1 R 1/15
Numeric value of quantity
SYNTAX: P0910

301015 SITUATIONAL RULE: Required when needed to further qualify the

eligibility or benefits being identified in the 2110D loop by quantity.
If not required by this implementation guide, do not send.

OD: 271B1_2110D_EB10__BenefitQuantity

IMPLEMENTATION NAME: Benefit Quantity

300471 Use this number for the quantity value as qualified by the
preceding data element (EB09).

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DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL EB11 1073 Yes/No Condition or Response Code O1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: 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.

300654 SITUATIONAL RULE: Required when needed to indicate if authorization or

certification is required for the eligibility or benefits being identified
in the 2110D loop. If not required by this implementation guide, do
not send.

OD: 271B1_2110D_EB11__AuthorizationorCertificationIndicator

IMPLEMENTATION NAME: Authorization or Certification Indicator

300823 Use code “U” - Unknown, In the event that a payer typically
responds Yes or No for some benefits, but the inquired benefit
requirements are not accessible or the rules are more complex than
can be determined using the data sent in the 270.
CODE DEFINITION

N No
U Unknown
Y Yes
SITUATIONAL EB12 1073 Yes/No Condition or Response Code O1 ID 1/1
Code indicating a Yes or No condition or response
SEMANTIC: 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.

300655 SITUATIONAL RULE: Required when needed to indicate if benefits are

considered In Plan Network or Out Of Plan Network for the
eligibility or benefits being identified in the 2110D loop. If not
required by this implementation guide, do not send.

OD: 271B1_2110D_EB12__InPlanNetworkIndicator

IMPLEMENTATION NAME: In Plan Network Indicator

300823 Use code “U” - Unknown, In the event that a payer typically
responds Yes or No for some benefits, but the inquired benefit
requirements are not accessible or the rules are more complex than
can be determined using the data sent in the 270.
CODE DEFINITION

N No
U Unknown
W Not Applicable
300973 Use code “W” - Not Applicable when benefits are
the same regardless of whether they are In Plan-
Network or Out of Plan-Network or a Plan-Network
does not apply to the benefit.
Y Yes

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SITUATIONAL EB13 C003 COMPOSITE MEDICAL PROCEDURE O1

IDENTIFIER
To identify a medical procedure by its standardized codes and applicable
modifiers

301016 SITUATIONAL RULE: Requiredwhen a Medical Procedure Code was used

from the 270 to determine the response being identified in the
2110D loop;
OR
Required when the Information Source supports Medical Procedure
Code based 271 transactions and a Medical Procedure Code is
available and appropriate for the eligibility or benefits being
identified in the 2110D loop.
If not required by this implementation guide or if EB03 is used, do
not send.

OD: 271B1_2110D_EB13_C003

300824 Use this composite data element only if an information source can
support this high level of functionality. The EB13 allows for a very
specific response.

300857 Not used if EB03 is present.

REQUIRED EB13 - 1 235 Product/Service ID Qualifier M ID 2/2
Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
SEMANTIC:
C003-01 qualifies C003-02 and C003-08.

OD:
271B1_2110D_EB13_C00301_ProductorServiceIDQualifier

IMPLEMENTATION NAME: Product or Service ID Qualifier

300470 Use this code to identify the external code list of the
following procedure/service code.
CODE DEFINITION

AD American Dental Association Codes

CODE SOURCE 135: American Dental Association
CJ Current Procedural Terminology (CPT) Codes
CODE SOURCE 133: Current Procedural Terminology (CPT) Codes
HC Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
CODE SOURCE 130: Healthcare Common Procedure Coding
System
ID International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) -
Procedure
CODE SOURCE 131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)

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DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION TECHNICAL REPORT • TYPE 3

IV Home Infusion EDI Coalition (HIEC) Product/Service

Code
300814 This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List
N4 National Drug Code in 5-4-2 Format
CODE SOURCE 240: National Drug Code by Format
ZZ Mutually Defined
301035 Use this code only for International Classification of
Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS).

CODE SOURCE 896: International Classification of

Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS)
REQUIRED EB13 - 2 234 Product/Service ID M AN 1/48
Identifying number for a product or service
SEMANTIC:
If C003-08 is used, then C003-02 represents the beginning value in the
range in which the code occurs.

OD: 271B1_2110D_EB13_C00302_ProcedureCode

IMPLEMENTATION NAME: Procedure Code

300476 Use this ID number for the product/service code as qualified

by the preceding data element.

SITUATIONAL EB13 - 3 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-03 modifies the value in C003-02 and C003-08.

301017 SITUATIONAL RULE: Required when a modifier was used from the
270 to determine the response being identified in the 2110D
loop;
OR
Required when a modifier clarifies/improves the accuracy of
the associated procedure code and the modifier is available.
If not required by this implementation guide, do not send.

OD: 271B1_2110D_EB13_C00303_ProcedureModifier

300755 Use this modifier for the procedure code identified in EB13-
2 if modifiers are needed to further specify the service.

408 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • EB
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

SITUATIONAL EB13 - 4 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-04 modifies the value in C003-02 and C003-08.

301017 SITUATIONAL RULE: Requiredwhen a modifier was used from the

270 to determine the response being identified in the 2110D
loop;
OR
Required when a modifier clarifies/improves the accuracy of
the associated procedure code and the modifier is available.
If not required by this implementation guide, do not send.

OD: 271B1_2110D_EB13_C00304_ProcedureModifier

300755 Use this modifier for the procedure code identified in EB13-
2 if modifiers are needed to further specify the service.
SITUATIONAL EB13 - 5 1339 Procedure Modifier O AN 2/2
This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-05 modifies the value in C003-02 and C003-08.

301017 SITUATIONAL RULE: Requiredwhen a modifier was used from the

270 to determine the response being identified in the 2110D
loop;
OR
Required when a modifier clarifies/improves the accuracy of
the associated procedure code and the modifier is available.
If not required by this implementation guide, do not send.

OD: 271B1_2110D_EB13_C00305_ProcedureModifier

300755 Use this modifier for the procedure code identified in EB13-
2 if modifiers are needed to further specify the service.

SITUATIONAL EB13 - 6 1339 Procedure Modifier O AN 2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
SEMANTIC:
C003-06 modifies the value in C003-02 and C003-08.

301017 SITUATIONAL RULE: Requiredwhen a modifier was used from the

270 to determine the response being identified in the 2110D
loop;
OR
Required when a modifier clarifies/improves the accuracy of
the associated procedure code and the modifier is available.
If not required by this implementation guide, do not send.

OD: 271B1_2110D_EB13_C00306_ProcedureModifier

300755 Use this modifier for the procedure code identified in EB13-
2 if modifiers are needed to further specify the service.

NOT USED EB13 - 7 352 Description O AN 1/80

APRIL 2008 409

005010X279 • 271 • 2110D • EB ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL EB13 - 8 234 Product/Service ID O AN 1/48

Identifying number for a product or service
SEMANTIC:
C003-08 represents the ending value in the range in which the code
occurs.

301062 SITUATIONAL RULE: Required

when the Information Source
desires to indicate a range of procedure codes. If not
required by this implementation guide, do not send.

OD: 271B1_2110D_EB13_C00308_ProductorServiceID

IMPLEMENTATION NAME: Product or Service ID

301063 EB13-2 indicates the beginning of value of the range of

procedure codes and EB13-8 represents the end of the
range of procedure codes. All procedure codes in the range
will apply.

SITUATIONAL EB14 C004 COMPOSITE DIAGNOSIS CODE POINTER O1

To identify one or more diagnosis code pointers

300914 SITUATIONAL RULE: Required when a 2100D HI segment is used and the
information in this 2110D EB loop is related to a diagnosis code. If
2100D HI segment is not used or if the information in this 2110D EB
loop is not related to a diagnosis code, do not send.

OD: 271B1_2110D_EB14_C004

301074 See requirements for the use of the 2100D HI segment for
additional information.
REQUIRED EB14 - 1 1328 Diagnosis Code Pointer M N0 1/2
A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-01 identifies the primary diagnosis code for this service line.

OD: 271B1_2110D_EB14_C00401_DiagnosisCodePointer

300915 This first pointer designates the primary diagnosis for this
EB segment. Remaining diagnosis pointers indicate
declining level of importance to the EB segment.
Acceptable values are 1 through 8, and correspond to
Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100D.
SITUATIONAL EB14 - 2 1328 Diagnosis Code Pointer O N0 1/2
A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-02 identifies the second diagnosis code for this service line.

300916 SITUATIONAL RULE: Required

when it is necessary to designate a
second diagnosis related to this EB segment. If not
required, do not send.

OD: 271B1_2110D_EB14_C00402_DiagnosisCodePointer

300917 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100D.

410 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • EB
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

SITUATIONAL EB14 - 3 1328 Diagnosis Code Pointer O N0 1/2

A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-03 identifies the third diagnosis code for this service line.

300918 SITUATIONAL RULE: Required

when it is necessary to designate a
third diagnosis related to this EB segment. If not required,
do not send.

OD: 271B1_2110D_EB14_C00403_DiagnosisCodePointer

300917 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100D.

SITUATIONAL EB14 - 4 1328 Diagnosis Code Pointer O N0 1/2

A pointer to the diagnosis code in the order of importance to this service
SEMANTIC:
C004-04 identifies the fourth diagnosis code for this service line.

300919 SITUATIONAL RULE: Required when it is necessary to designate a

fourth diagnosis related to this EB segment. If not required,
do not send.

OD: 271B1_2110D_EB14_C00404_DiagnosisCodePointer

300917 Acceptable values are 1 through 8, and correspond to

Composite Data Elements 01 through 08 in the Health Care
Diagnosis Code HI segment in loop 2100D.

APRIL 2008 411

 005010X279 • 271 • 2110D • HSD ASC X12N • INSURANCE SUBCOMMITTEE
HEALTH CARE SERVICES DELIVERY TECHNICAL REPORT • TYPE 3
HEALTH CARE SERVICES DELIVERY 005010X279
HEALTH CARE• 271 • 2110D •DELIVERY
SERVICES HSD
HSD

SEGMENT DETAIL
595
300
HSD - HEALTH CARE SERVICES DELIVERY
X12 Segment Name: Health Care Services Delivery
X12 Purpose: To specify the delivery pattern of health care services
X12 Syntax: 1. P0102
If either HSD01 or HSD02 is present, then the other is required.
2. C0605
If HSD06 is present, then HSD05 is required.
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 9

Usage: SITUATIONAL

36
06
30 Situational Rule: Required when needed to identify a specific delivery or usage pattern
associated with the benefits identified in either EB03 or EB13. If not
required by this implementation guide, do not send.

512
300 TR3 Example: HSD✽VS✽30✽✽✽22~
Thirty visits per service year

681
300 TR3 Example: HSD✽VS✽12✽WK✽3✽34✽1~
Twelve visits, three visits per week, for 1 month.

DIAGRAM

HSD01 673 HSD02 380 HSD03 355 HSD04 1167 HSD05 615 HSD06 616
Quantity Quantity Unit/Basis Sample Sel
✽ Time Period ✽ Number of
HSD ✽ Qualifier
✽ ✽
Meas Code
✽
Modulus Qualifier Periods
X1 ID 2/2 X1 R 1/15 O1 ID 2/2 O1 R 1/6 X1 ID 1/2 O1 N0 1/3

HSD07 678 HSD08 679

✽ Ship/Del or ✽ Ship/Del
~
Calend Code Time Code
O1 ID 1/2 O1 ID 1/1

412 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • HSD
TECHNICAL REPORT • TYPE 3 HEALTH CARE SERVICES DELIVERY

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

SITUATIONAL HSD01 673 Quantity Qualifier X1 ID 2/2

Code specifying the type of quantity
SYNTAX: P0102

300734 SITUATIONAL RULE: Required when identifying type and quantity benefits
identified. If not required by this implementation guide, do not send.

OD: 271B1_2110D_HSD01__QuantityQualifier

300756 Required if HSD02 is used.

CODE DEFINITION

DY Days
FL Units
HS Hours
MN Month
VS Visits
SITUATIONAL HSD02 380 Quantity X1 R 1/15
Numeric value of quantity
SYNTAX: P0102

300734 SITUATIONAL RULE: Required when identifying type and quantity benefits
identified. If not required by this implementation guide, do not send.

OD: 271B1_2110D_HSD02__BenefitQuantity

IMPLEMENTATION NAME: Benefit Quantity

300769 Required if HSD01 is used.

SITUATIONAL HSD03 355 Unit or Basis for Measurement Code O1 ID 2/2
Code specifying the units in which a value is being expressed, or manner in which
a measurement has been taken

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110D_HSD03__UnitorBasisforMeasurementCode

CODE DEFINITION

DA Days
MO Months
VS Visit
WK Week
YR Years

APRIL 2008 413

005010X279 • 271 • 2110D • HSD ASC X12N • INSURANCE SUBCOMMITTEE
HEALTH CARE SERVICES DELIVERY TECHNICAL REPORT • TYPE 3

SITUATIONAL HSD04 1167 Sample Selection Modulus O1 R 1/6

To specify the sampling frequency in terms of a modulus of the Unit of Measure,
e.g., every fifth bag, every 1.5 minutes

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110D_HSD04__SampleSelectionModulus

SITUATIONAL HSD05 615 Time Period Qualifier X1 ID 1/2

Code defining periods
SYNTAX: C0605

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110D_HSD05__TimePeriodQualifier

CODE DEFINITION

6 Hour
7 Day
21 Years
22 Service Year
23 Calendar Year
24 Year to Date
25 Contract
26 Episode
27 Visit
28 Outlier
29 Remaining
30 Exceeded
31 Not Exceeded
32 Lifetime
33 Lifetime Remaining
34 Month
35 Week
SITUATIONAL HSD06 616 Number of Periods O1 N0 1/3
Total number of periods
SYNTAX: C0605

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110D_HSD06__PeriodCount

IMPLEMENTATION NAME: Period Count

414 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • HSD
TECHNICAL REPORT • TYPE 3 HEALTH CARE SERVICES DELIVERY

SITUATIONAL HSD07 678 Ship/Delivery or Calendar Pattern Code O1 ID 1/2

Code which specifies the routine shipments, deliveries, or calendar pattern

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110D_HSD07__DeliveryFrequencyCode

IMPLEMENTATION NAME: Delivery Frequency Code

CODE DEFINITION

1 1st Week of the Month

2 2nd Week of the Month
3 3rd Week of the Month
4 4th Week of the Month
5 5th Week of the Month
6 1st & 3rd Weeks of the Month
7 2nd & 4th Weeks of the Month
8 1st Working Day of Period
9 Last Working Day of Period
A Monday through Friday
B Monday through Saturday
C Monday through Sunday
D Monday
E Tuesday
F Wednesday
G Thursday
H Friday
J Saturday
K Sunday
L Monday through Thursday
M Immediately
N As Directed
O Daily Mon. through Fri.
P 1/2 Mon. & 1/2 Thurs.
Q 1/2 Tues. & 1/2 Thurs.
R 1/2 Wed. & 1/2 Fri.
S Once Anytime Mon. through Fri.
SG Tuesday through Friday
SL Monday, Tuesday and Thursday
SP Monday, Tuesday and Friday
SX Wednesday and Thursday
SY Monday, Wednesday and Thursday
SZ Tuesday, Thursday and Friday
T 1/2 Tue. & 1/2 Fri.
U 1/2 Mon. & 1/2 Wed.
V 1/3 Mon., 1/3 Wed., 1/3 Fri.

APRIL 2008 415

005010X279 • 271 • 2110D • HSD ASC X12N • INSURANCE SUBCOMMITTEE
HEALTH CARE SERVICES DELIVERY TECHNICAL REPORT • TYPE 3

W Whenever Necessary
X 1/2 By Wed., Bal. By Fri.
Y None (Also Used to Cancel or Override a Previous
Pattern)
SITUATIONAL HSD08 679 Ship/Delivery Pattern Time Code O1 ID 1/1
Code which specifies the time for routine shipments or deliveries

300736 SITUATIONAL RULE: Required

when needed to provide further information
about the number and frequency of benefits. If not required by this
implementation guide, do not send.

OD: 271B1_2110D_HSD08__DeliveryPatternTimeCode

IMPLEMENTATION NAME: Delivery Pattern Time Code

CODE DEFINITION

A 1st Shift (Normal Working Hours)

B 2nd Shift
C 3rd Shift
D A.M.
E P.M.
F As Directed
G Any Shift
Y None (Also Used to Cancel or Override a Previous
Pattern)

416 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • REF
TECHNICAL REPORT • TYPE 3 DEPENDENT ADDITIONAL IDENTIFICATION
REFERENCE INFORMATION DEPENDENT• ADDITIONAL
005010X279 271 • 2110D •IDENTIFICATION
REF
REF

SEGMENT DETAIL
521
300
REF - DEPENDENT ADDITIONAL
IDENTIFICATION
X12 Segment Name: Reference Information
X12 Purpose: To specify identifying information
X12 Syntax: 1. R0203
At least one of REF02 or REF03 is required.
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 9

Usage: SITUATIONAL

18
10
30 Situational Rule: Required when the Information Source requires one or more of these
additional identifiers for subsequent EDI transactions (see Section 1.4.7);
OR
Required when an additional identifier is associated with the eligibility or
benefits being identified in the 2110D loop.
If not required by this implementation guide, do not send.

643
300 TR3 Notes: 1. Use this segment for reference identifiers related only to the 2110D
loop that it is contained in (e.g. Other or Additional Payer’s identifiers).

075
301 2. Use this segment to identify other or additional reference numbers for
the entity identified. The type of reference number is determined by
the qualifier in REF01. Only one occurrence of each REF01 code value
may be used in the 2110D loop.

513
300 TR3 Example: REF✽G1✽653745725~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

Reference Reference Description Reference
REF ✽ Ident Qual
✽
Ident
✽ ✽
Identifier ~
M1 ID 2/3 X1 AN 1/50 X1 AN 1/80 O1

APRIL 2008 417

005010X279 • 271 • 2110D • REF ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ADDITIONAL IDENTIFICATION TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED REF01 128 Reference Identification Qualifier M1 ID 2/3

Code qualifying the Reference Identification

OD: 271B1_2110D_REF01__ReferenceIdentificationQualifier

300454 Use this code to specify or qualify the type of reference number
that is following in REF02, REF03, or both.

301030 Use “1W”, “49”, “F6”, and “NQ” only in a 2110D loop with EB01 =
“R”.

301076 Only one occurrence of each REF01 code value may be used in the
2110D loop.
CODE DEFINITION

18 Plan Number
1L Group or Policy Number
300622 Use this code only if it cannot be determined if the
number is a Group Number or a Policy number. Use
codes “IG” or “6P” when they can be determined.
1W Member Identification Number
49 Family Unit Number
301019 Required when the Information Source is a
Pharmacy Benefit Manager (PBM) and the individual
has a suffix to their member ID number that is
required for use in the NCPDP Telecom Standard in
the Insurance Segment in field 303-C3 Person Code.
If not required by this implementation Guide, do not
send.

NOTE: For all other uses, the Family Unit Number

(suffix) is considered a part of the Member ID
number and is used to uniquely identify the
individual and must be returned at the end of the
Member ID number in 2110D REF02 if REF01 is “1W”.
6P Group Number
9F Referral Number
ALS Alternative List ID
300977 Allows the source to identify the list identifier of a
list of drugs and its alternative drugs with the
associated formulary status for the patient.
CLI Coverage List ID
300978 Allows the source to identify the list identifier of a
list of drugs that have coverage limitations for the
associated patient.
F6 Health Insurance Claim (HIC) Number
FO Drug Formulary Number
G1 Prior Authorization Number
IG Insurance Policy Number

418 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • REF
TECHNICAL REPORT • TYPE 3 DEPENDENT ADDITIONAL IDENTIFICATION

N6 Plan Network Identification Number

NQ Medicaid Recipient Identification Number
REQUIRED REF02 127 Reference Identification X1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: R0203

OD: 271B1_2110D_REF02__DependentEligibilityorBenefitIdentifier

IMPLEMENTATION NAME: Dependent Eligibility or Benefit Identifier

300453 Use this information for the reference number as qualified by the
preceding data element (REF01).
SITUATIONAL REF03 352 Description X1 AN 1/80
A free-form description to clarify the related data elements and their content
SYNTAX: R0203

300864 SITUATIONAL RULE: Required

when REF01 = “18", ”6P" or “N6" and a
name needs to be associated with the corresponding identifier. If
not required by this implementation guide, do not send.

OD: 271B1_2110D_REF03__PlanGrouporPlanNetworkName

IMPLEMENTATION NAME: Plan, Group or Plan Network Name

NOT USED REF04 C040 REFERENCE IDENTIFIER O1

APRIL 2008 419

 005010X279 • 271 • 2110D • DTP ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY/BENEFIT DATE TECHNICAL REPORT • TYPE 3
DATE OR TIME OR PERIOD DEPENDENT• ELIGIBILITY/BENEFIT
005010X279 271 • 2110D • DTP DATE
DTP

SEGMENT DETAIL
604
300
DTP - DEPENDENT ELIGIBILITY/BENEFIT
DATE
X12 Segment Name: Date or Time or Period
X12 Purpose: To specify any or all of a date, a time, or a time period
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 20

Usage: SITUATIONAL

20
10
30 Situational Rule: Required when the individual has active coverage with multiple plans or
multiple plan periods apply (See 2100D DTP segment);
OR
Required when needed to convey dates associated with the eligibility or
benefits being identified in the 2110D loop.
If not required by this implementation guide, do not send.

830
300 TR3 Notes: 1. When using the DTP segment in the 2110D loop this date applies only
to the 2110D Eligibility or Benefit Information (EB) loop in which it is
located.

If a DTP segment with the same DTP01 value is present in the 2100D
loop, the date is overridden for only this 2110D Eligibility or Benefit
Information (EB) loop.

496
300 TR3 Example: DTP✽472✽D8✽19960624~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251

Date/Time
✽ Date Time ✽ Date Time
DTP ✽ Qualifier Format Qual Period ~
M1 ID 3/3 M1 ID 2/3 M1 AN 1/35

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED DTP01 374 Date/Time Qualifier M1 ID 3/3

Code specifying type of date or time, or both date and time

OD: 271B1_2110D_DTP01__DateTimeQualifier

IMPLEMENTATION NAME: Date Time Qualifier

CODE DEFINITION

096 Discharge
193 Period Start
194 Period End
198 Completion
290 Coordination of Benefits

420 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • DTP
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY/BENEFIT DATE

291 Plan
301105 Use code 291 only if multiple plans apply to the
individual or multiple plan periods apply. Dates
supplied in this DPT segment only apply to the
2110D loop in which it occurs.
292 Benefit
295 Primary Care Provider
304 Latest Visit or Consultation
307 Eligibility
318 Added
346 Plan Begin
301106 Use code 346 only if multiple plans apply to the
individual or multiple plan periods apply. Dates
supplied in this DPT segment only apply to the
2110D loop in which it occurs.
348 Benefit Begin
349 Benefit End
356 Eligibility Begin
357 Eligibility End
435 Admission
472 Service
636 Date of Last Update
771 Status
REQUIRED DTP02 1250 Date Time Period Format Qualifier M1 ID 2/3
Code indicating the date format, time format, or date and time format
SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

OD: 271B1_2110D_DTP02__DateTimePeriodFormatQualifier

300463 Use this code to specify the format of the date(s)/time(s) that follow
in the next data element.
CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

RD8 Range of Dates Expressed in Format CCYYMMDD-
CCYYMMDD
REQUIRED DTP03 1251 Date Time Period M 1 AN 1/35
Expression of a date, a time, or range of dates, times or dates and times

OD: 271B1_2110D_DTP03__EligibilityorBenefitDateTimePeriod

IMPLEMENTATION NAME: Eligibility or Benefit Date Time Period

300462 Use this date for the date(s) as qualified by the preceding data
elements.

APRIL 2008 421

 005010X279 • 271 • 2110D • AAA ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT REQUEST VALIDATION TECHNICAL REPORT • TYPE 3
REQUEST VALIDATION DEPENDENT• REQUEST
005010X279 271 • 2110D • AAA
VALIDATION
AAA

SEGMENT DETAIL
601
300
AAA - DEPENDENT REQUEST VALIDATION
X12 Segment Name: Request Validation
X12 Purpose: To specify the validity of the request and indicate follow-up action authorized
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 9

Usage: SITUATIONAL

57
07
30 Situational Rule: Required when the request could not be processed at a system or
application level when specifically related to specific eligibility/benefit
inquiry data contained in the original 270 transaction’s dependent
eligibility/benefit inquiry information loop (Loop 2110D) and to indicate
what action the originator of the request transaction should take. If not
required by this implementation guide, do not send.

758
300 TR3 Notes: 1. Use this segment to indicate problems in processing the transaction
specifically related to specific eligibility/benefit inquiry data contained
in the original 270 transaction’s dependent eligibility/benefit inquiry
information loop (Loop 2110D).

497
300 TR3 Example: AAA✽N✽✽70✽C~

DIAGRAM

AAA01 1073 AAA02 559 AAA03 901 AAA04 889

✽ Yes/No Cond ✽ Agency Reject Follow-up

AAA Resp Code Qual Code
✽
Reason Code
✽
Act Code ~
M1 ID 1/1 O1 ID 2/2 O1 ID 2/2 O1 ID 1/1

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED AAA01 1073 Yes/No Condition or Response Code M1 ID 1/1

Code indicating a Yes or No condition or response
SEMANTIC: AAA01 designates whether the request is valid or invalid. Code “Y”
indicates that the code is valid; code “N” indicates that the code is invalid.

OD: 271B1_2110D_AAA01__ValidRequestIndicator

IMPLEMENTATION NAME: Valid Request Indicator

CODE DEFINITION

N No
300620 Use this code to indicate that the request or an
element in the request is not valid. The transaction
has been rejected as identified by the code in
AAA03.

422 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • AAA
TECHNICAL REPORT • TYPE 3 DEPENDENT REQUEST VALIDATION

Y Yes
300621 Use this code to indicate that the request is valid,
however the transaction has been rejected as
identified by the code in AAA03.
NOT USED AAA02 559 Agency Qualifier Code O1 ID 2/2
REQUIRED AAA03 901 Reject Reason Code O1 ID 2/2
Code assigned by issuer to identify reason for rejection

OD: 271B1_2110D_AAA03__RejectReasonCode

300438 Use this code for the reason why the transaction was unable to be
processed successfully. This may indicate problems with the
system, the application, or the data content.
CODE DEFINITION

15 Required application data missing

33 Input Errors
300880 Use this code only when data is present in this
transaction and no other Reject Reason Code is
valid for describing the error. Detail of the error
must be supplied in the MSG segment of the 2110D
loop containing this Reject Reason Code.
52 Service Dates Not Within Provider Plan Enrollment
53 Inquired Benefit Inconsistent with Provider Type
54 Inappropriate Product/Service ID Qualifier
55 Inappropriate Product/Service ID
56 Inappropriate Date
57 Invalid/Missing Date(s) of Service
60 Date of Birth Follows Date(s) of Service
61 Date of Death Precedes Date(s) of Service
62 Date of Service Not Within Allowable Inquiry Period
63 Date of Service in Future
69 Inconsistent with Patient’s Age
70 Inconsistent with Patient’s Gender
98 Experimental Service or Procedure
AA Authorization Number Not Found
300881 Use this code only when the Referral Number or
Prior Authorization Number in 2110D REF02 is not
found.
AE Requires Primary Care Physician Authorization
AF Invalid/Missing Diagnosis Code(s)
AG Invalid/Missing Procedure Code(s)
300867 Use this code for errors with Procedure Codes in
EQ02-2 or Procedure Code Modifiers in EQ02-3
through EQ02-6.

APRIL 2008 423

005010X279 • 271 • 2110D • AAA ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT REQUEST VALIDATION TECHNICAL REPORT • TYPE 3

AO Additional Patient Condition Information Required

300868 Use this code only if the Information Source
supports responding to a detailed eligibility request
and the information can be processed from a 270
transaction received by the Information Source but
was not received and is needed to respond
appropriately.
CI Certification Information Does Not Match Patient
300882 Use this code only when the Referral Number or
Prior Authorization Number in 2110D REF02 is
found but is not associated with the subscriber.
E8 Requires Medical Review
IA Invalid Authorization Number Format
300883 Use this code only when the Referral Number or
Prior Authorization Number in 2110D REF02 is not
formatted properly.
MA Missing Authorization Number
300884 Use this code only when the Referral Number or
Prior Authorization Number has been issued and is
missing in 2110D REF02 but is needed to respond
appropriately.
REQUIRED AAA04 889 Follow-up Action Code O1 ID 1/1
Code identifying follow-up actions allowed

OD: 271B1_2110D_AAA04__FollowupActionCode

300437 Use this code to instruct the recipient of the 271 about what action
needs to be taken, if any, based on the validity code and the reject
reason code (if applicable).
CODE DEFINITION

C Please Correct and Resubmit

N Resubmission Not Allowed
R Resubmission Allowed
W Please Wait 30 Days and Resubmit
X Please Wait 10 Days and Resubmit
Y Do Not Resubmit; We Will Hold Your Request and
Respond Again Shortly

424 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • MSG
TECHNICAL REPORT • TYPE 3 MESSAGE TEXT
MESSAGE TEXT • 271 • 2110D • MSG
005010X279TEXT
MESSAGE
MSG

SEGMENT DETAIL
598
300
MSG - MESSAGE TEXT
X12 Segment Name: Message Text
X12 Purpose: To provide a free-form format that allows the transmission of text information
X12 Syntax: 1. C0302
If MSG03 is present, then MSG02 is required.
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 10

Usage: SITUATIONAL

80
09
30 Situational Rule: Required when the eligibility or benefit information cannot be codified in
existing data elements (including combinations of multiple data elements
and segments);
AND
Required when this information is pertinent to the eligibility or benefit
response.
If not required by this implementation guide, do not send.

504
300 TR3 Notes: 1. Free form text or description fields are not recommended because
they require human interpretation.

858
300 2. Under no circumstances can an information source use the MSG
segment to relay information that can be sent using codified
information in existing data elements (including combinations of
multiple data elements and segments). If the information cannot be
codified, then cautionary use of the MSG segment is allowed as a
short term solution. It is highly recommended that the entity needing
to use the MSG segment approach X12N with data maintenance to
solve the long term business need, so the use of the MSG segment
can be avoided for that issue.

683
300 3. Benefit Disclaimers are strongly discouraged. See section 1.4.11
Disclaimers Within the Transaction. Under no circumstances are more
than one MSG segment to be used for a Benefit Disclaimer per
individual response.

682
300 TR3 Example: MSG✽Free form text is discouraged~

DIAGRAM

MSG01 933 MSG02 934 MSG03 1470

Free-Form Printer Number
MSG ✽
Message Txt
✽
Ctrl Code
✽ ~
M1 AN 1/264 X1 ID 2/2 O1 N0 1/9

APRIL 2008 425

005010X279 • 271 • 2110D • MSG ASC X12N • INSURANCE SUBCOMMITTEE
MESSAGE TEXT TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED MSG01 933 Free-form Message Text M 1 AN 1/264

Free-form message text

OD: 271B1_2110D_MSG01__FreeFormMessageText

IMPLEMENTATION NAME: Free Form Message Text

NOT USED MSG02 934 Printer Carriage Control Code X1 ID 2/2
NOT USED MSG03 1470 Number O1 N0 1/9

426 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2115D • III
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION
INFORMATION DEPENDENT• ELIGIBILITY
005010X279 271 • 2115DOR
• IIIBENEFIT ADDITIONAL INFORMATION
III

SEGMENT DETAIL
699
300
III - DEPENDENT ELIGIBILITY OR BENEFIT
ADDITIONAL INFORMATION
X12 Segment Name: Information
X12 Purpose: To report information
X12 Syntax: 1. P0102
If either III01 or III02 is present, then the other is required.
2. L030405
If III03 is present, then at least one of III04 or III05 are required.
Loop: 2115D — DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL
INFORMATION Loop Repeat: 10

Segment Repeat: 1

Usage: SITUATIONAL

00
07
30 Situational Rule: Required when III segments in Loop 2110D of the 270 Inquiry were used in
the determination of the eligibility or benefit response;
OR
Required when needed to identify limitations in the benefits explained in
the corresponding Loop 2110D (such as if benefits are limited to a type of
facility).
If not required by this implementation guide, do not send.

701
300 TR3 Notes: 1. This segment has two purposes. Information that was received in III
segments in Loop 2110D of the 270 Inquiry and was used in the
determination of the eligibility or benefit response must be returned.
If information was provided in III segments of Loop 2110D but was not
used in the determination of the eligibility or benefits it must not be
returned. This segment can also be used to identify limitations in the
benefits explained in the corresponding Loop 2110D, such as if
benefits are limited to a type of facility.

688
300 2. Use this segment to identify Nature of Injury Codes and/or Facility
Type as they relate to the information provided in the EB segment.

689
300 3. Use the III segment only if an information source can support this
high level functionality.

690
300 4. Use this segment only one time for the Facility Type Code.

685
300 TR3 Example: III✽ZZ✽21~
III✽✽✽44✽Broken bones and third degree burns~

APRIL 2008 427

005010X279 • 271 • 2115D • III ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION TECHNICAL REPORT • TYPE 3

DIAGRAM

III01 1270 III02 1271 III03 1136 III04 933 III05 380 III06 C001
Code List Industry Code
✽ Free-Form ✽ Quantity Composite
III ✽ Qual Code
✽
Code
✽
Category Message Txt
✽
Unit of Mea
X1 ID 1/3 X1 AN 1/30 O1 ID 2/2 X1 AN 1/264 X1 R 1/15 O1

III07 752 III08 752 III09 752

Layer/Posit Layer/Posit Layer/Posit
✽ ✽ ✽ ~
Code Code Code
O1 ID 2/2 O1 ID 2/2 O1 ID 2/2

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

SITUATIONAL III01 1270 Code List Qualifier Code X1 ID 1/3

Code identifying a specific industry code list
SYNTAX: P0102

300981 SITUATIONAL RULE: Requiredwhen identifying a Nature of Injury Code or

a Facility Type Code. If not required by this implementation guide,
do not send.

OD: 271B1_2115D_III01__CodeListQualifierCode

300872 Use this code to specify if the code that is following in the III02 is a
Nature of Injury Code or a Facility Type Code.
CODE DEFINITION

GR National Council on Compensation Insurance (NCCI)

Nature of Injury Code
CODE SOURCE 284: Nature of Injury Code
NI Nature of Injury Code
300873 Other code source as specified by the jurisdiction.
CODE SOURCE 284: Nature of Injury Code
CODE SOURCE 407: Occupational Injury and Illness Classification
Manual
ZZ Mutually Defined
300739 Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of
Service Codes for Professional Claims.
SITUATIONAL III02 1271 Industry Code X1 AN 1/30
Code indicating a code from a specific industry code list
SYNTAX: P0102

300981 SITUATIONAL RULE: Required when identifying a Nature of Injury Code or

a Facility Type Code. If not required by this implementation guide,
do not send.

OD: 271B1_2115D_III02__IndustryCode

300874 If III01 is GR, use this element for NCCI Nature of Injury code from
code source 284.

428 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2115D • III
TECHNICAL REPORT • TYPE 3 DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION

300875 If III01 is NI, use this element for Nature of Injury code from code
source 407.

300691 If III01 is ZZ, use this element for codes identifying a place of
service from code source 237. As a courtesy, the codes are listed
below, however, the code list is thought to be complete at the time
of publication of this implementation guideline. Since this list is
subject to change, only codes contained in the document available
from code source 237 are to be supported in this transaction and
take precedence over any and all codes listed here.

01 Pharmacy
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-based Facility
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service

APRIL 2008 429

005010X279 • 271 • 2115D • III ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL III03 1136 Code Category O1 ID 2/2

Specifies the situation or category to which the code applies
SYNTAX: L030405
SEMANTIC: III03 is used to categorize III04.

300876 SITUATIONAL RULE: Required when III01 and III02 are not present or if
additional information is needed (see III04). If not required by this
implementation guide or if III01 is ZZ, do not send.

OD: 271B1_2115D_III03__CodeCategory

CODE DEFINITION

44 Nature of Injury
SITUATIONAL III04 933 Free-form Message Text X1 AN 1/264
Free-form message text
SYNTAX: L030405

300877 SITUATIONAL RULE: Required

when III03 = “44”. If not required by this
implementation guide, do not send.

OD: 271B1_2115D_III04__InjuredBodyPartName

IMPLEMENTATION NAME: Injured Body Part Name

NOT USED III05 380 Quantity X1 R 1/15
NOT USED III06 C001 COMPOSITE UNIT OF MEASURE O1
NOT USED III07 752 Surface/Layer/Position Code O1 ID 2/2
NOT USED III08 752 Surface/Layer/Position Code O1 ID 2/2
NOT USED III09 752 Surface/Layer/Position Code O1 ID 2/2

430 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • LS
TECHNICAL REPORT • TYPE 3 LOOP HEADER
LOOP HEADER 005010X279
LOOP HEADER• 271 • 2110D • LS
LS

SEGMENT DETAIL
e
Non
LS - LOOP HEADER
X12 Segment Name: Loop Header
X12 Purpose: To indicate that the next segment begins a loop
X12 Semantic: 1. One loop may be nested contained within another loop, provided the inner
nested loop terminates before the outer loop. When specified by the
standard setting body as mandatory, this segment in combination with “LE”,
must be used. It is not to be used if not specifically set forth for use. The
loop identifier in the loop header and trailer must be identical. The value for
the identifier is the loop ID of the required loop segment. The loop ID
number is given on the transaction set diagram in the appropriate ASC X12
version/release.
X12 Comments: 1. See Figures Appendix for an explanation of the use of the LS and LE
segments.
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 1

Usage: SITUATIONAL

21
10
30 Situational Rule: Required when Loop 2120D is used. If not required by this implementation
guide, do not send.

759
300 TR3 Notes: 1. Use this segment to identify the beginning of the Dependent Benefit
Related Entity Name loop. Because both the subscriber’s name loop
and this loop begin with NM1 segments, the LS and LE segments are
used to differentiate these two loops.

804
300 TR3 Example: LS✽2120~

DIAGRAM

LS01 447
Loop ID
LS ✽ Code
M1 AN 1/4

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED LS01 447 Loop Identifier Code M 1 AN 1/4

The loop ID number given on the transaction set diagram is the value for this data
element in segments LS and LE

OD: 271B1_2110D_LS01__LoopIdentifierCode

300805 This data element must have the value of “2120”.

APRIL 2008 431

 005010X279 • 271 • 2120D • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT BENEFIT RELATED ENTITY NAME TECHNICAL REPORT • TYPE 3
INDIVIDUAL OR ORGANIZATIONAL NAME DEPENDENT• BENEFIT
005010X279 271 • 2120D • NM1 ENTITY NAME
RELATED
NM1

SEGMENT DETAIL
551
300
NM1 - DEPENDENT BENEFIT RELATED
ENTITY NAME
X12 Segment Name: Individual or Organizational Name
X12 Purpose: To supply the full name of an individual or organizational entity
X12 Syntax: 1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
3. C1203
If NM112 is present, then NM103 is required.
Loop: 2120D — DEPENDENT BENEFIT RELATED ENTITY NAME Loop Repeat:
23

Segment Repeat: 1

Usage: SITUATIONAL

60
07
30 Situational Rule: Required when provider was identified in 2100D PRV02 and PRV03 by
Identification Number (not Taxonomy Code) in the 270 Inquiry and was
used in the determination of the eligibility or benefit response;
OR
Required when needed to identify an entity associated with the eligibility
or benefits being identified in the 2110D loop such as a provider (e.g.
primary care provider), an individual, an organization, another payer, or
another information source;
If not required by this implementation guide, do not send.

499
300 TR3 Example: NM1✽P3✽1✽JONES✽MARCUS✽✽✽MD✽SV✽111223333~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038
Entity ID Entity Type Name Last/ Name Name Name
NM1 ✽ Code
✽
Qualifier
✽
Org Name
✽
First
✽
Middle
✽
Prefix
M1 ID 2/3 M1 ID 1/1 X1 AN 1/60 O1 AN 1/35 O1 AN 1/25 O1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

Name ID Code ID Entity Entity ID Name Last/
✽ ✽ ✽ ✽ ✽ ✽ ~
Suffix Qualifier Code Relat Code Code Org Name
O1 AN 1/10 X1 ID 1/2 X1 AN 2/80 X1 ID 2/2 O1 ID 2/3 O1 AN 1/60

432 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120D • NM1
TECHNICAL REPORT • TYPE 3 DEPENDENT BENEFIT RELATED ENTITY NAME

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED NM101 98 Entity Identifier Code M1 ID 2/3

Code identifying an organizational entity, a physical location, property or an
individual

OD: 271B1_2120D_NM101__EntityIdentifierCode

CODE DEFINITION

13 Contracted Service Provider

1I Preferred Provider Organization (PPO)
301022 Use if identifying a Preferred Provider Organization
(PPO) by name or identification number. May also
be used if identifying the Network that benefits are
restricted to when 2110D EB12 = “Y” (In-Network).
1P Provider
2B Third-Party Administrator
36 Employer
73 Other Physician
FA Facility
GP Gateway Provider
GW Group
I3 Independent Physicians Association (IPA)
IL Insured or Subscriber
300692 Use if identifying an insured or subscriber to a plan
other than the information source (such as in a co-
ordination of benefits situation).
LR Legal Representative
OC Origin Carrier
300842 Use if identifying an organization that added
information relating to other insurance.
P3 Primary Care Provider
P4 Prior Insurance Carrier
P5 Plan Sponsor
PR Payer
PRP Primary Payer
SEP Secondary Payer
TTP Tertiary Payer
VN Vendor
VY Organization Completing Configuration Change
300843 Use if identifying an organization that changed
information relating to other insurance.
X3 Utilization Management Organization

APRIL 2008 433

005010X279 • 271 • 2120D • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT BENEFIT RELATED ENTITY NAME TECHNICAL REPORT • TYPE 3

REQUIRED NM102 1065 Entity Type Qualifier M1 ID 1/1

Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.

OD: 271B1_2120D_NM102__EntityTypeQualifier

300440 Use this code to indicate whether the entity is an individual person
or an organization.
CODE DEFINITION

1 Person
2 Non-Person Entity
SITUATIONAL NM103 1035 Name Last or Organization Name X1 AN 1/60
Individual last name or organizational name
SYNTAX: C1203

301023 SITUATIONAL RULE: Requiredwhen needed to identify by name an entity

associated with the eligibility or benefits being identified in the
2110D loop such as a provider (e.g. Primary Care Provider), an
individual, an organization, another payer, or another information
source.
OR
Required when NM109 is not used.
If not required by this implementation guide, do not send.

OD:
271B1_2120D_NM103__BenefitRelatedEntityLastorOrganizationName

IMPLEMENTATION NAME: Benefit Related Entity Last or Organization Name

300449 Use this name for the organization name if the entity type qualifier
is a non-person entity. Otherwise, this will be the individual’s last
name.
SITUATIONAL NM104 1036 Name First O 1 AN 1/35
Individual first name

300651 SITUATIONAL RULE: Required when NM102 is “1" and NM103 is used. If
not required by this implementation guide, do not send.

OD: 271B1_2120D_NM104__BenefitRelatedEntityFirstName

IMPLEMENTATION NAME: Benefit Related Entity First Name

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25
Individual middle name or initial

300985 SITUATIONAL RULE: Required when NM102 is “1" and the Last Name in
NM103 and First Name in NM104 are not sufficient to identify the
individual. If not required by this implementation guide, may be
provided at sender’s discretion, but cannot be required by the
receiver.

OD: 271B1_2120D_NM105__BenefitRelatedEntityMiddleName

IMPLEMENTATION NAME: Benefit Related Entity Middle Name

NOT USED NM106 1038 Name Prefix O 1 AN 1/10

434 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120D • NM1
TECHNICAL REPORT • TYPE 3 DEPENDENT BENEFIT RELATED ENTITY NAME

SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10

Suffix to individual name

300647 SITUATIONAL RULE: Required

when NM102 is “1" and the Last Name in
NM103 and First Name in NM104 and/or Middle Name in 2100A
NM105 are not sufficient to identify the individual. If not required by
this implementation guide, may be provided at sender’s discretion,
but cannot be required by the receiver.

OD: 271B1_2120D_NM107__BenefitRelatedEntityNameSuffix

IMPLEMENTATION NAME: Benefit Related Entity Name Suffix

301024 Use for name suffix only (e.g. Sr, Jr, II, III, etc.).
SITUATIONAL NM108 66 Identification Code Qualifier X1 ID 1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX: P0809

301025 SITUATIONAL RULE: Requiredwhen needed to identify by Identification

Code an entity associated with the eligibility or benefits being
identified in the 2110D loop such as a provider (e.g. Primary Care
Provider), an individual, an organization, another payer, or another
information source.
OR
Required when NM103 is not used.
If not required by this implementation guide, may be provided at
sender’s discretion, but cannot be required by the receiver.

OD: 271B1_2120D_NM108__IdentificationCodeQualifier

300624 If the entity being identified is a provider and the National Provider
ID is mandated for use, code value “XX” must be used, otherwise,
one of the other codes may be used. If the entity being identified is
a payer and the CMS National PlanID is mandated for use, code
value “XV” must be used, otherwise, one of the other codes may be
used. If the entity being identified is an individual, the “HIPAA
Individual Identifier” must be used once this identifier has been
adopted, otherwise, one of the other codes may be used.
CODE DEFINITION

24 Employer’s Identification Number

34 Social Security Number
300658 The social security number may not be used for any
Federally administered programs such as Medicare.
46 Electronic Transmitter Identification Number (ETIN)
FA Facility Identification
FI Federal Taxpayer’s Identification Number
II Standard Unique Health Identifier for each Individual
in the United States
301068 Under the Health Insurance Portability and
Accountability Act of 1996, the Secretary of the
Department of Health and Human Services may
adopt a standard individual identifier for use in this
transaction.

APRIL 2008 435

005010X279 • 271 • 2120D • NM1 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT BENEFIT RELATED ENTITY NAME TECHNICAL REPORT • TYPE 3

MI Member Identification Number

300705 Use this code to identify the entity’s Member
Identification Number associated with a payer other
than the information source in Loop 2100A. This
code may only be used prior to the mandated use of
code “II”.
NI National Association of Insurance Commissioners
(NAIC) Identification
PI Payor Identification
PP Pharmacy Processor Number
SV Service Provider Number
XV Centers for Medicare and Medicaid Services PlanID
CODE SOURCE 540: Centers for Medicare and Medicaid Services
PlanID
XX Centers for Medicare and Medicaid Services
National Provider Identifier
CODE SOURCE 537: Centers for Medicare & Medicaid Services
National Provider Identifier
SITUATIONAL NM109 67 Identification Code X1 AN 2/80
Code identifying a party or other code
SYNTAX: P0809

301025 SITUATIONAL RULE: Requiredwhen needed to identify by Identification

Code an entity associated with the eligibility or benefits being
identified in the 2110D loop such as a provider (e.g. Primary Care
Provider), an individual, an organization, another payer, or another
information source.
OR
Required when NM103 is not used.
If not required by this implementation guide, may be provided at
sender’s discretion, but cannot be required by the receiver.

OD: 271B1_2120D_NM109__BenefitRelatedEntityIdentifier

IMPLEMENTATION NAME: Benefit Related Entity Identifier

300448 Use this code for the reference number as qualified by the
preceding data element (NM108).

436 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120D • NM1
TECHNICAL REPORT • TYPE 3 DEPENDENT BENEFIT RELATED ENTITY NAME

SITUATIONAL NM110 706 Entity Relationship Code X1 ID 2/2

Code describing entity relationship
SYNTAX: C1110
COMMENT: NM110 and NM111 further define the type of entity in NM101.

300837 SITUATIONAL RULE: Required

when needed to indicate the Benefit
Related Entity’s relationship to the patient when EB01 = “R”, the
coverage is based on the Benefit Related Entity and the
relationship is known. If not required by this implementation guide,
may be provided at sender’s discretion, but cannot be required by
the receiver.

OD: 271B1_2120D_NM110__BenefitRelatedEntityRelationshipCode

IMPLEMENTATION NAME: Benefit Related Entity Relationship Code

CODE DEFINITION

01 Parent
02 Child
27 Domestic Partner
41 Spouse
48 Employee
65 Other
72 Unknown
NOT USED NM111 98 Entity Identifier Code O1 ID 2/3
NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

APRIL 2008 437

 005010X279 • 271 • 2120D • N3 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT BENEFIT RELATED ENTITY ADDRESS TECHNICAL REPORT • TYPE 3
PARTY LOCATION DEPENDENT• BENEFIT
005010X279 271 • 2120D • N3 ENTITY ADDRESS
RELATED
N3

SEGMENT DETAIL
552
300
N3 - DEPENDENT BENEFIT RELATED ENTITY
ADDRESS
X12 Segment Name: Party Location
X12 Purpose: To specify the location of the named party
Loop: 2120D — DEPENDENT BENEFIT RELATED ENTITY NAME

Segment Repeat: 1

Usage: SITUATIONAL

61
07
30 Situational Rule: Required when needed to further identify the entity or individual in loop
2120D NM1 and the information is available. If not required by this
implementation guide, do not send.

444
300 TR3 Notes: 1. Use this segment to identify address information for an entity.

485
300 TR3 Example: N3✽201 PARK AVENUE✽SUITE 300~

DIAGRAM

N301 166 N302 166

Address Address
N3 ✽ Information
✽
Information ~
M1 AN 1/55 O1 AN 1/55

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N301 166 Address Information M 1 AN 1/55

Address information

OD: 271B1_2120D_N301__BenefitRelatedEntityAddressLine

IMPLEMENTATION NAME: Benefit Related Entity Address Line

300455 Use this information for the first line of the address information.

SITUATIONAL N302 166 Address Information O 1 AN 1/55

Address information

300708 SITUATIONAL RULE: Requiredwhen a second address line exists and is

available. If not required by this implementation guide, do not send.

OD: 271B1_2120D_N302__BenefitRelatedEntityAddressLine

IMPLEMENTATION NAME: Benefit Related Entity Address Line

300456 Use this information for the second line of the address information.

438 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120D • N4
TECHNICAL REPORT • TYPE 3 DEPENDENT BENEFIT RELATED ENTITY CITY, STATE, ZIP CODE
GEOGRAPHIC LOCATION DEPENDENT• BENEFIT
005010X279 271 • 2120D • N4 ENTITY CITY, STATE, ZIP CODE
RELATED
N4

SEGMENT DETAIL
553
300
N4 - DEPENDENT BENEFIT RELATED ENTITY
CITY, STATE, ZIP CODE
X12 Segment Name: Geographic Location
X12 Purpose: To specify the geographic place of the named party
X12 Syntax: 1. E0207
Only one of N402 or N407 may be present.
2. C0605
If N406 is present, then N405 is required.
3. C0704
If N407 is present, then N404 is required.
Loop: 2120D — DEPENDENT BENEFIT RELATED ENTITY NAME

Segment Repeat: 1

Usage: SITUATIONAL

46
10
30 Situational Rule: Required when needed to further identify the entity or individual in loop
2120D NM1 and the information is available. If not required by this
implementation guide, do not send.

038
301 TR3 Notes: 1. Use this segment to identify address information for an entity.

920
300 TR3 Example: N4✽KANSAS CITY✽MO✽64108~

DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310
City State or Postal Country Location Location
N4 ✽ Name
✽
Prov Code
✽
Code
✽
Code
✽
Qualifier
✽
Identifier
O1 AN 2/30 X1 ID 2/2 O1 ID 3/15 X1 ID 2/3 X1 ID 1/2 O1 AN 1/30

N407 1715

✽ Country Sub ~
Code
X1 ID 1/3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED N401 19 City Name O 1 AN 2/30

Free-form text for city name
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.

OD: 271B1_2120D_N401__BenefitRelatedEntityCityName

IMPLEMENTATION NAME: Benefit Related Entity City Name

APRIL 2008 439

005010X279 • 271 • 2120D • N4 ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT BENEFIT RELATED ENTITY CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

SITUATIONAL N402 156 State or Province Code X1 ID 2/2

Code (Standard State/Province) as defined by appropriate government agency
SYNTAX: E0207
COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

300921 SITUATIONAL RULE: Required

when the address is in the United States of
America, including its territories, or Canada. If not required by this
implementation guide, do not send.

OD: 271B1_2120D_N402__BenefitRelatedEntityStateCode

IMPLEMENTATION NAME: Benefit Related Entity State Code

CODE SOURCE 22: States and Provinces

SITUATIONAL N403 116 Postal Code O1 ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)

300922 SITUATIONAL RULE: Requiredwhen the address is in the United States of

America, including its territories, or Canada, or when a postal code
exists for the country in N404. If not required by this
implementation guide, do not send.

OD: 271B1_2120D_N403__BenefitRelatedEntityPostalZoneorZIPCode

IMPLEMENTATION NAME: Benefit Related Entity Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes
SITUATIONAL N404 26 Country Code X1 ID 2/3
Code identifying the country
SYNTAX: C0704

300923 SITUATIONAL RULE: Required

when the address is outside the United
States of America. If not required by this implementation guide, do
not send.

OD: 271B1_2120D_N404__BenefitRelatedEntityCountryCode

IMPLEMENTATION NAME: Benefit Related Entity Country Code

CODE SOURCE 5: Countries, Currencies and Funds

300924 Use the alpha-2 country codes from Part 1 of ISO 3166.

440 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120D • N4
TECHNICAL REPORT • TYPE 3 DEPENDENT BENEFIT RELATED ENTITY CITY, STATE, ZIP CODE

SITUATIONAL N405 309 Location Qualifier X1 ID 1/2

Code identifying type of location
SYNTAX: C0605

301027 SITUATIONAL RULE: Required

when needed by CHAMPUS/TRICARE or
CHAMPVA to communicate the DOD Health Service Region. If not
required by this implementation guide, do not send.

OD: 271B1_2120D_N405__BenefitRelatedEntityLocationQualifier

IMPLEMENTATION NAME: Benefit Related Entity Location Qualifier

CODE SOURCE 206: Government Bill of Lading Office Code

301039 Use this element only to communicate the Department of Defense

Health Service Region.
CODE DEFINITION

RJ Region
300693 Use this code only to communicate the Department
of Defense Health Service Region in N406.
SITUATIONAL N406 310 Location Identifier O 1 AN 1/30
Code which identifies a specific location
SYNTAX: C0605

301027 SITUATIONAL RULE: Required

when needed by CHAMPUS/TRICARE or
CHAMPVA to communicate the DOD Health Service Region. If not
required by this implementation guide, do not send.

OD:
271B1_2120D_N406__BenefitRelatedEntityDODHealthServiceRegion

IMPLEMENTATION NAME: Benefit Related Entity DOD Health Service Region

301028 Use this element only to communicate the Department of Defense

Health Service Region.

301040 CODE SOURCE DOD1: Military Health Systems Functional Area

Manual - Data.

SITUATIONAL N407 1715 Country Subdivision Code X1 ID 1/3

Code identifying the country subdivision
SYNTAX: E0207, C0704

300925 SITUATIONAL RULE: Required when the address is not in the United
States of America, including its territories, or Canada, and the
country in N404 has administrative subdivisions such as but not
limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.

OD:
271B1_2120D_N407__BenefitRelatedEntityCountrySubdivisionCode

IMPLEMENTATION NAME: Benefit Related Entity Country Subdivision Code

CODE SOURCE 5: Countries, Currencies and Funds

300926 Use the country subdivision codes from Part 2 of ISO 3166.

APRIL 2008 441

 005010X279 • 271 • 2120D • PER ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION TECHNICAL REPORT • TYPE 3
ADMINISTRATIVE COMMUNICATIONS CONTACT 005010X279 • BENEFIT
DEPENDENT 271 • 2120D • PER ENTITY CONTACT INFORMATION
RELATED
PER

SEGMENT DETAIL
554
300
PER - DEPENDENT BENEFIT RELATED
ENTITY CONTACT INFORMATION
X12 Segment Name: Administrative Communications Contact
X12 Purpose: To identify a person or office to whom administrative communications should be
directed
X12 Syntax: 1. P0304
If either PER03 or PER04 is present, then the other is required.
2. P0506
If either PER05 or PER06 is present, then the other is required.
3. P0708
If either PER07 or PER08 is present, then the other is required.
Loop: 2120D — DEPENDENT BENEFIT RELATED ENTITY NAME

Segment Repeat: 3

Usage: SITUATIONAL

87
09
30 Situational Rule: Required when Contact Information exists and is available. If not required
by this implementation guide, do not send.

803
300 TR3 Notes: 1. Use this segment when needed to identify a contact name and/or
communications number for the entity identified. This segment allows
for three contact numbers to be listed. This segment is used when the
information source wishes to provide a contact for the entity identified
in loop 2120D NM1.

If telephone extension is sent, it should always be in the occurrence

of the communications number following the actual phone number.
See the example for an illustration.

702
300 2. If this segment is used, at a minimum either PER02 must be used or
PER03 and PER04 must be used. It is recommended that at least
PER02, PER03 and PER04 are sent if this segment is used.

706
300 3. When the communication number represents a telephone number in
the United States and other countries using the North American
Dialing Plan (for voice, data, fax, etc.), the communication number
should always include the area code and phone number using the
format AAABBBCCCC. Where AAA is the area code, BBB is the
telephone number prefix, and CCCC is the telephone number (e.g.
(534)224-2525 would be represented as 5342242525). The extension,
when applicable, should be included in the communication number
immediately after the telephone number.

486
300 TR3 Example: PER✽IC✽BILLING DEPT✽TE✽2128763654✽EX✽2104✽FX✽2128769304~

442 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120D • PER
TECHNICAL REPORT • TYPE 3 DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION

DIAGRAM

PER01 366 PER02 93 PER03 365 PER04 364 PER05 365 PER06 364
Contact Name Comm Comm Comm Comm
PER ✽ Funct Code
✽ ✽
Number Qual
✽
Number
✽
Number Qual
✽
Number
M1 ID 2/2 O1 AN 1/60 X1 ID 2/2 X1 AN 1/256 X1 ID 2/2 X1 AN 1/256

PER07 365 PER08 364 PER09 443

Comm Comm Contact Inq
✽ ✽ ✽ ~
Number Qual Number Reference
X1 ID 2/2 X1 AN 1/256 O1 AN 1/20

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PER01 366 Contact Function Code M1 ID 2/2

Code identifying the major duty or responsibility of the person or group named

OD: 271B1_2120D_PER01__ContactFunctionCode

300457 Use this code to specify the type of person or group to which the
contact number applies.
CODE DEFINITION

IC Information Contact
SITUATIONAL PER02 93 Name O 1 AN 1/60
Free-form name

301088 SITUATIONAL RULE: Required when the name of the individual to contact
is not already defined or is different than the name within 2120D
NM1 segment and the name is available;
OR
Required when PER03 and PER04 are not present.
If not required by this implementation guide, may be provided at
sender’s discretion, but cannot be required by the receiver.

OD: 271B1_2120D_PER02__BenefitRelatedEntityContactName

IMPLEMENTATION NAME: Benefit Related Entity Contact Name

300989 Use this name for the individual’s name or group’s name to use
when contacting the individual or organization.

APRIL 2008 443

005010X279 • 271 • 2120D • PER ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL PER03 365 Communication Number Qualifier X1 ID 2/2

Code identifying the type of communication number
SYNTAX: P0304

300990 SITUATIONAL RULE: Required

when PER02 is not present or when a
communication number, e-mail or Web address is to be sent in
addition to the contact name. If not required by this implementation
guide, may be provided at sender’s discretion, but cannot be
required by the receiver.

OD: 271B1_2120D_PER03__CommunicationNumberQualifier

300459 Use this code to specify what type of communication number is

following.
CODE DEFINITION

ED Electronic Data Interchange Access Number

EM Electronic Mail
FX Facsimile
TE Telephone
UR Uniform Resource Locator (URL)
WP Work Phone Number
SITUATIONAL PER04 364 Communication Number X1 AN 1/256
Complete communications number including country or area code when
applicable
SYNTAX: P0304

300990 SITUATIONAL RULE: Required

when PER02 is not present or when a
communication number, e-mail or Web address is to be sent in
addition to the contact name. If not required by this implementation
guide, may be provided at sender’s discretion, but cannot be
required by the receiver.

OD:
271B1_2120D_PER04__BenefitRelatedEntityCommunicationNumber

IMPLEMENTATION NAME: Benefit Related Entity Communication Number

300514 The format for US domestic phone numbers is:

AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number

300991 Use this for the communication number or URL as qualified by the
preceding data element.

444 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120D • PER
TECHNICAL REPORT • TYPE 3 DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION

SITUATIONAL PER05 365 Communication Number Qualifier X1 ID 2/2

Code identifying the type of communication number
SYNTAX: P0506

300992 SITUATIONAL RULE: Required

when a second communication contact
number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD: 271B1_2120D_PER05__CommunicationNumberQualifier

300459 Use this code to specify what type of communication number is

following.
CODE DEFINITION

ED Electronic Data Interchange Access Number

EM Electronic Mail
EX Telephone Extension
FX Facsimile
TE Telephone
UR Uniform Resource Locator (URL)
WP Work Phone Number
SITUATIONAL PER06 364 Communication Number X1 AN 1/256
Complete communications number including country or area code when
applicable
SYNTAX: P0506

300992 SITUATIONAL RULE: Required

when a second communication contact
number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD:
271B1_2120D_PER06__BenefitRelatedEntityCommunicationNumber

IMPLEMENTATION NAME: Benefit Related Entity Communication Number

300514 The format for US domestic phone numbers is:

AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number

300991 Use this for the communication number or URL as qualified by the
preceding data element.

APRIL 2008 445

005010X279 • 271 • 2120D • PER ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION TECHNICAL REPORT • TYPE 3

SITUATIONAL PER07 365 Communication Number Qualifier X1 ID 2/2

Code identifying the type of communication number
SYNTAX: P0708

300993 SITUATIONAL RULE: Required

when a third communication contact
number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD: 271B1_2120D_PER07__CommunicationNumberQualifier

300459 Use this code to specify what type of communication number is

following.
CODE DEFINITION

ED Electronic Data Interchange Access Number

EM Electronic Mail
EX Telephone Extension
FX Facsimile
TE Telephone
UR Uniform Resource Locator (URL)
WP Work Phone Number
SITUATIONAL PER08 364 Communication Number X1 AN 1/256
Complete communications number including country or area code when
applicable
SYNTAX: P0708

300993 SITUATIONAL RULE: Required when a third communication contact

number, e-mail or Web address is needed. If not required by this
implementation guide, do not send.

OD:
271B1_2120D_PER08__BenefitRelatedEntityCommunicationNumber

IMPLEMENTATION NAME: Benefit Related Entity Communication Number

300514 The format for US domestic phone numbers is:

AAABBBCCCC
AAA = Area Code
BBBCCCC = Local Number

300991 Use this for the communication number or URL as qualified by the
preceding data element.
NOT USED PER09 443 Contact Inquiry Reference O 1 AN 1/20

446 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2120D • PRV
TECHNICAL REPORT • TYPE 3 DEPENDENT BENEFIT RELATED PROVIDER INFORMATION
PROVIDER INFORMATION DEPENDENT• BENEFIT
005010X279 271 • 2120D • PRV PROVIDER INFORMATION
RELATED
PRV

SEGMENT DETAIL
555
300
PRV - DEPENDENT BENEFIT RELATED
PROVIDER INFORMATION
X12 Segment Name: Provider Information
X12 Purpose: To specify the identifying characteristics of a provider
X12 Syntax: 1. P0203
If either PRV02 or PRV03 is present, then the other is required.
Loop: 2120D — DEPENDENT BENEFIT RELATED ENTITY NAME

Segment Repeat: 1

Usage: SITUATIONAL

26
10
30 Situational Rule: Required when needed either to identify a provider’s role or associate a
specialty type related to the service identified in the 2110D loop. If not
required by this implementation guide, do not send.

762
300 TR3 Notes: 1. If identifying a type of specialty associated with the services identified
in loop 2110D, use code PXC in PRV02 and the appropriate code in
PRV03.

844
300 2. If there is a PRV segment in 2100B or 2100D, this PRV overrides it for
this occurrence of the 2110D loop.

033
301 TR3 Example: PRV✽PE✽PXC✽207Q00000X~

DIAGRAM

PRV01 1221 PRV02 128 PRV03 127 PRV04 156 PRV05 C035 PRV06 1223
Provider Reference Reference State or Provider Provider
PRV ✽ Code
✽
Ident Qual
✽
Ident
✽
Prov Code
✽
Spec. Inf.
✽
Org Code ~
M1 ID 1/3 X1 ID 2/3 X1 AN 1/50 O1 ID 2/2 O1 O1 ID 3/3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED PRV01 1221 Provider Code M1 ID 1/3

Code identifying the type of provider

OD: 271B1_2120D_PRV01__ProviderCode

CODE DEFINITION

AD Admitting
AT Attending
BI Billing
CO Consulting
CV Covering
H Hospital
HH Home Health Care
LA Laboratory

APRIL 2008 447

005010X279 • 271 • 2120D • PRV ASC X12N • INSURANCE SUBCOMMITTEE
DEPENDENT BENEFIT RELATED PROVIDER INFORMATION TECHNICAL REPORT • TYPE 3

OT Other Physician
P1 Pharmacist
P2 Pharmacy
PC Primary Care Physician
PE Performing
R Rural Health Clinic
RF Referring
SB Submitting
SK Skilled Nursing Facility
SU Supervising
SITUATIONAL PRV02 128 Reference Identification Qualifier X1 ID 2/3
Code qualifying the Reference Identification
SYNTAX: P0203

300629 SITUATIONAL RULE: Required

when needed to identify a provider’s
specialty type related to the service identified in the 2110D loop. If
not required by this implementation guide, do not send.

OD: 271B1_2120D_PRV02__ReferenceIdentificationQualifier

CODE DEFINITION

PXC Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy
SITUATIONAL PRV03 127 Reference Identification X1 AN 1/50
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
SYNTAX: P0203

300629 SITUATIONAL RULE: Required

when needed to identify a provider’s
specialty type related to the service identified in the 2110D loop. If
not required by this implementation guide, do not send.

OD: 271B1_2120D_PRV03__ProviderIdentifier

IMPLEMENTATION NAME: Provider Identifier

300489 Use this reference number as qualified by the preceding data

element (PRV02).
NOT USED PRV04 156 State or Province Code O1 ID 2/2
NOT USED PRV05 C035 PROVIDER SPECIALTY INFORMATION O1
NOT USED PRV06 1223 Provider Organization Code O1 ID 3/3

448 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 271 • 2110D • LE
TECHNICAL REPORT • TYPE 3 LOOP TRAILER
LOOP TRAILER 005010X279
LOOP • 271 • 2110D • LE
TRAILER
LE

SEGMENT DETAIL
600
300
LE - LOOP TRAILER
X12 Segment Name: Loop Trailer
X12 Purpose: To indicate that the loop immediately preceding this segment is complete
X12 Semantic: 1. One loop may be nested contained within another loop, provided the inner
nested loop terminates before the other loop. When specified by the
standards setting body as mandatory, this segment in combination with
“LS”, must be used. It is not to be used if not specifically set forth for use.
The loop identifier in the loop header and trailer must be identical. The
value for the identifier is the loop ID of the required loop beginning
segment. The loop ID number is given on the transaction set diagram in the
appropriate ASC X12 version/release.
X12 Comments: 1. See Figures Appendix for an explanation of the use of the LE and LS
segments.
Loop: 2110D — DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

Segment Repeat: 1

Usage: SITUATIONAL

47
10
30 Situational Rule: Required when Loop 2120D is used. If not required by this implementation
guide, do not send.

077
301 TR3 Notes: 1. Use this segment to identify the end of the Dependent Benefit Related
Entity Name loop. Because both the dependent’s name loop and this
loop begin with NM1 segments, the LS and LE segments are used to
differentiate these two loops.

801
300 TR3 Example: LE✽2120~

DIAGRAM

LE01 447
Loop ID
LE ✽ Code
M1 AN 1/4

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED LE01 447 Loop Identifier Code M 1 AN 1/4

The loop ID number given on the transaction set diagram is the value for this data
element in segments LS and LE

OD: 271B1_2110D_LE01__LoopIdentifierCode

300810 This data element must have the value of “2120".

APRIL 2008 449

 005010X279 • 271 • SE ASC X12N • INSURANCE SUBCOMMITTEE
TRANSACTION SET TRAILER TECHNICAL REPORT • TYPE 3
TRANSACTION SET TRAILER TRANSACTION
005010X279 • 271
SET• SE
TRAILER
SE

SEGMENT DETAIL
605
300
SE - TRANSACTION SET TRAILER
X12 Segment Name: Transaction Set Trailer
X12 Purpose: To indicate the end of the transaction set and provide the count of the
transmitted segments (including the beginning (ST) and ending (SE) segments)
X12 Comments: 1. SE is the last segment of each transaction set.
Segment Repeat: 1

Usage: REQUIRED

764
300 TR3 Notes: 1. Use this segment to mark the end of a transaction set and provide
control information on the total number of segments included in the
transaction set.

765
300 TR3 Example: SE✽52✽0001~

DIAGRAM

SE01 96 SE02 329

Number of TS Control
SE ✽ Inc Segs
✽
Number ~
M1 N0 1/10 M1 AN 4/9

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED SE01 96 Number of Included Segments M1 N0 1/10

Total number of segments included in a transaction set including ST and SE
segments

OD: 271B1__SE01__TransactionSegmentCount

IMPLEMENTATION NAME: Transaction Segment Count

REQUIRED SE02 329 Transaction Set Control Number M 1 AN 4/9
Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set

OD: 271B1__SE02__TransactionSetControlNumber

300586 The transaction set control numbers in ST02 and SE02 must be
identical. This unique number also aids in error resolution
research. Start with a number, for example “0001", and increment
from there. This number must be unique within a specific functional
group (segments GS through GE) and interchange, but can repeat
in other groups and interchanges.

450 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270/271
TECHNICAL REPORT • TYPE 3 HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

3 Examples
The following information is associated with the information source, information receiver,
subscriber, and dependent used in the following examples in this section:

Payer (Information Source) ABC Company

Payer Identification Number 842610001

Provider (Information Receiver) Clinic Bone and Joint Clinic

Service Provider Number 2000035
Facility Network Identification Number
234899
55 High Street Seattle, WA, 98123
Communication Contact Name Billing
Department
Phone Number 206-555-1212
Extension 2805
FAX 206-555-1213

Provider (Information Receiver) Marcus Jones

Individual Physician Service Provider Number 0202034
Provider Plan Network Identification
Number 129
Communication Contact Name M. Murphy
Phone Number 206-555-1212
Extension 3694
FAX 206-555-1214

Subscriber Robert B. Smith Subscriber

(Subscriber/Patient)
Member Identification Number
11122333301
Date of Birth 19430519
Male
Group or Policy Number 599119
29 Fremont St, Apt # 1, Peace, NY, 10023

APRIL 2008 451

005010X279 • 270/271 ASC X12N • INSURANCE SUBCOMMITTEE
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE TECHNICAL REPORT • TYPE 3

Dependent Mary Smith Dependent (Patient)

Social Security Number 003221234
Date of Birth 19781014
Female
Relationship to Subscriber Child

3.1 Example 1
Example 1 is for a subscriber who is also the patient. There are two responses in this
section. The first response is a positive response where the subscriber was found. The
second response is a rejection for a provider not authorized to access the payer's eligibility
system.

3.1.1 Request
Generic request by a clinic for the patient's (subscriber) eligibility.
This is an example of an eligibility request from a clinic to a payer processed in Real
Time (see Section 1.4.3 - Batch and Real Time). The clinic is inquiring if the patient (the
subscriber) has coverage.The request is from Bone and Joint Clinic to the ABC Company.
This example uses the Primary Search Option (see Section 1.4.8 - Search Options) for
a subscriber who is the patient and is for a generic request for Eligibility (see
Section 1.4.7 - Implementation-Compliant Use of the 270/271 Transaction Set).

ST*270*1234*005010X279~ Transaction Set ID Code = 270 (Eligibility, Coverage

or Benefit Inquiry)
Transaction Set Control Number = 1234
Implementation Convention Reference =
005010X279

BHT*0022*13*10001234*20060501*1319~ Hierarchical Structure Code = 0022 (Information

Source, Information Receiver, Subscriber,
Dependent)
Transaction Set Purpose Code = 13 (Request)
Identification
Reference Identification = 10001234
Date = 20060501 (May 1, 2006)
Time = 1:19 PM

HL*1**20*1~ Hierarchical ID Number = 1

Hierarchical Parent ID Number = * not used
Hierarchical Level Code = 20 (Information Source)
Hierarchical Child Code = 1

452 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270/271
TECHNICAL REPORT • TYPE 3 HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

NM1*PR*2*ABC COMPANY*****PI* Entity Identifier Code = PR (Payer)

842610001~ Entity Type Qualifier = 2 (Non-person)
Last Name = ABC Company
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = PI (Payer
Identification)
Identification Code = 842610001

HL*2*1*21*1~ Hierarchical ID Number = 2

Hierarchical Parent ID Number = 1
Hierarchical Level Code = 21
Hierarchical Child Code = 1

NM1*1P*2*BONE AND JOINT Entity Identifier Code = 1P (Provider)

CLINIC*****SV*2000035~ Entity Type Qualifier = 2 (Non-Person)
Last Name = Bone and Joint Clinic
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = SV Service Provider
Number
Identification Code = 2000035

HL*3*2*22*0~ Hierarchical ID Number = 3

Hierarchical Parent ID Number = 2
Hierarchical Level Code = 22
Hierarchical Child Code = 0

TRN*1*93175-012547*9877281234~ Trace Type Code = 1 (Current Transaction Trace

Number)
Reference Identification = 93175-012547
Originating Company Identifier = 9877281234
Reference Identification = * not used

NM1*IL*1*SMITH*ROBERT****MI* Entity Identifier Code = IL (Insured or Subscriber)

11122333301~ Entity Type Qualifier = 1 (Person)
Last Name = Smith
First Name = Robert
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = MI (Member
Identification Number)
Identification Code = 11122333301

APRIL 2008 453

005010X279 • 270/271 ASC X12N • INSURANCE SUBCOMMITTEE
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE TECHNICAL REPORT • TYPE 3

DMG*D8*19430519~ Date Time Period Format = D8 (Date Expressed in

Format CCYYMMDD)
Date Time Period = 19430519

DTP*291*D8*20060501~ Date/Time Qualifier = 291 (Plan)

Date Time Period Format Qualifier D8 (Dates
Expressed in Format CCYYMMDD)
Date Time Period = 20060501 (May 1, 2006)

EQ*30~ Service Type Code = 30 (Health Benefit Plan

Coverage

SE*13*1234~ Number of Included Segments = 13

Transaction Set Control Number = 1234

3.1.2 Response
Response to a generic request by a clinic for the patient's (subscriber) eligibility.
This is an example of an eligibility response from a payer to a clinic based on the request
in Section 3.1.1 - Request. The request is from Bone and Joint Clinic to the ABC
Company. This response illustrates the required components outlined in
Section 1.4.7 - Implementation-Compliant Use of the 270/271 Transaction Set. The
payer has indicated the patient (the subscriber) has active coverage for the health plan,
the beginning date for their coverage with the plan, active coverage for all the benefits
outlined in Section 1.4.7 - Implementation-Compliant Use of the 270/271 Transaction
Set and they have a Primary Care Physician.

ST*271*4321*005010X279~ Transaction Set ID Code = 271 (Eligibility, Coverage

or Benefit Information)
Transaction Set Control Number = 4321
Implementation Convention Reference =
005010X279

BHT*0022*11*10001234*20060501*1319~ Hierarchical Structure Code = 0022 (Information

Source, Information Receiver, Subscriber,
Dependent)
Transaction Set Purpose Code = 11 (Response)
Identification
Reference Identification = 10001234
Date = 20060501 (May 1, 2006)
Time = 1:19 PM

454 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270/271
TECHNICAL REPORT • TYPE 3 HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

HL*1**20*1~ Hierarchical ID Number = 1

Hierarchical Parent ID Number = * not used
Hierarchical Level Code = 20 (Information Source)
Hierarchical Child Code = 1

NM1*PR*2*ABC COMPANY*****PI* Entity Identifier Code = PR (Payer)

842610001~ Entity Type Qualifier = 2 (Non-Person Entity)
Last Name = ABC Company
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = PI (Payer
Identification)
Identification Code = 842610001

HL*2*1*21*1~ Hierarchical ID Number = 2

Hierarchical Parent ID Number = 1
Hierarchical Level Code = 21 (Information Receiver)
Hierarchical Child Code = 1

NM1*1P*2*BONE AND JOINT Entity Identifier Code = 1P (Provider)

CLINIC*****SV*2000035~ Entity Type Qualifier = 2 (Non-Person Entity)
Last Name = Bone and Joint Clinic
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = SV (Service Provider
Number)
Identification Code = 2000035

HL*3*2*22*0~ Hierarchical ID Number = 3

Hierarchical Parent ID Number = 2
Hierarchical Level Code = 22 (Subscriber)
Hierarchical Child Code = 0

TRN*2*93175-012547*9877281234~ Trace Type Code = 2 (Referenced Transaction

Trace Number)
Reference Identification = 93175-012547
Originating Company Identifier = 9877281234
Reference Identification = * not used

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NM1*IL*1*SMITH*JOHN****MI* Entity Identifier Code = IL (Insured or Subscriber)

123456789~ Entity Type Qualifier = 1 (Person)
Last Name = Smith
First Name = John
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = MI (Member
Identification)
Identification Code = 123456789

N3*15197 BROADWAY AVENUE*APT 215~ Address Information = 15197 BROADWAY

AVENUE
Address Information = APT 215

N4*KANSAS CITY*MO*64108~ City = KANSAS CITY

State or Prov Code = MO
Postal Code = 64108

DMG*D8*19630519*M~ Date Time Period Format = D8 (Date Expressed in

Format CCYYMMDD)
Date Time Period = 19630519
Gender Code = M (Male)

DTP*346*D8*20060101~ Date/Time Qualifier = 346 (Plan Begin)

Date Time Period Format Qualifier D8 (Dates
Expressed in Format CCYYMMDD)
Date Time Period = 20060101 (January 1, 2006)

EB*1**30**GOLD 123 PLAN~ Eligibility or Benefit Information Code = 1 (Active

Coverage)
Coverage Level Code = * not used
Service Type Code = 30 (Health Benefit Plan
Coverage)
Insurance Type Code = * not used
Plan Coverage Description = Gold 123 Plan

EB*L~ Eligibility or Benefit Information Code = L (Primary

Care Provider)

LS*2120~ Loop Identifier Code = 2120

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NM1*P3*1*JONES*MARCUS****SV* Entity Identifier Code = P3 (Primary Care Provider)

0202034~ Entity Type Qualifier = 1 (Person)
Last Name = Jones
First Name = Marcus
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = SV Service Provider
Number
Identification Code = 0202034

LE*2120~ Loop Identifier Code = 2120

EB*1**1^33^35^47^86^88^98^AL^MH^UC~ Eligibility or Benefit Information Code = 1 (Active

Coverage)
Coverage Level Code = * not used
Service Type Code = 1 (Medical Care)
Service Type Code = 33 (Chiropractic)
Service Type Code = 35 (Dental Care)
Service Type Code = 47 (Hospital)
Service Type Code = 86 (Emergency Services)
Service Type Code = 88 (Pharmacy)
Service Type Code = 98 (Professional (Physician)
Visit - Office)
Service Type Code = AL (Vision (Optometry))
Service Type Code = MH (Mental Health)
Service Type Code = UC (Urgent Care)

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EB*B**1^33^35^47^86^88^98^AL^MH^ Eligibility or Benefit Information Code = B

UC*HM*GOLD 123 PLAN*27*10*****Y~ (Co-Payment)
Coverage Level Code = * not used
Service Type Code = 1 (Medical Care)
Service Type Code = 33 (Chiropractic)
Service Type Code = 35 (Dental Care)
Service Type Code = 47 (Hospital)
Service Type Code = 86 (Emergency Services)
Service Type Code = 88 (Pharmacy)
Service Type Code = 98 (Professional (Physician)
Visit - Office)
Service Type Code = AL (Vision (Optometry))
Service Type Code = MH (Mental Health)
Service Type Code = UC (Urgent Care)
Insurance Type Code =HM (Health Management
Organization (HMO))
Plan Coverage Description = GOLD 123 PLAN
Time Period Qualifier = 27 (Visit)
Monetary Value = 10 (Dollar)
Percent = * not used
Quantity Qualifier = * not used
Quantity = * not used
Yes/No Condition Or Response Code
(Certification/Authorization Indicator) = * not used
Yes/No Condition Or Response Code (In Plan
Network Indicator) = Y (Yes – In Network)

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EB*B**1^33^35^47^86^88^98^AL^MH^ Eligibility or Benefit Information Code = B

UC*HM*GOLD 123 PLAN*27*30*****N~ (Co-Payment)
Coverage Level Code = * not used
Service Type Code = 1 (Medical Care)
Service Type Code = 33 (Chiropractic)
Service Type Code = 35 (Dental Care)
Service Type Code = 47 (Hospital)
Service Type Code = 86 (Emergency Services)
Service Type Code = 88 (Pharmacy)
Service Type Code = 98 (Professional (Physician)
Visit - Office)
Service Type Code = AL (Vision (Optometry))
Service Type Code = MH (Mental Health)
Service Type Code = UC (Urgent Care)
Insurance Type Code =HM (Health Management
Organization (HMO))
Plan Coverage Description = GOLD 123 PLAN
Time Period Qualifier = 27 (Visit)
Monetary Value = 30 (Dollar)
Percent = * not used
Quantity Qualifier = * not used
Quantity = * not used
Yes/No Condition Or Response Code
(Certification/Authorization Indicator) = * not used
Yes/No Condition Or Response Code (In Plan
Network Indicator) = N (No – Out of Network)

SE*22*4321~ Number of Included Segments = 22

Transaction Set Control Number = 4321

3.1.3 Response
Error response from the payer to a clinic that is not eligible for inquiries with the
payer.
This is an example of an eligibility response from a payer to a clinic based on the request
in example Section 3.1.1 - Request. The request validation segment is used in this
example to indicate that the provider is not eligible for inquiries.

ST*271*4323*005010X279~ Transaction Set ID Code = 271 (Eligibility, Coverage

or Benefit Information)
Transaction Set Control Number = 4323
Implementation Convention Reference =
005010X279

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BHT*0022*11*10001234*20060501*1319~ Hierarchical Structure Code = 0022 (Information

Source, Information Receiver, Subscriber,
Dependent)
Transaction Set Purpose Code = 11 (Response)
Identification
Reference Identification = 10001234
Date = 20060501 (May 1, 2006)
Time = 1:19 PM

HL*1**20*1~ Hierarchical ID Number = 1

Hierarchical Parent ID Number = * not used
Hierarchical Level Code = 20 (Information Source)
Hierarchical Child Code = 1

NM1*PR*2*ABC COMPANY*****PI* Entity Identifier Code = PR (Payer)

842610001~ Entity Type Qualifier = 2 (Non-person)
Last Name = ABC Company
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = PI (Payer
Identification)
Identification Code = 842610001

HL*2*1*21*1~ Hierarchical ID Number = 2

Hierarchical Parent ID Number = 1
Hierarchical Level Code = 21
Hierarchical Child Code = 1

NM1*1P*2*BONE AND JOINT Entity Identifier Code = 1P (Provider)

CLINIC*****SV*2000035~ Entity Type Qualifier = 2 (Non-Person)
Last Name = Bone and Joint Clinic
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = SV Service Provider
Number
Identification Code = 2000035

AAA*Y**50*N~ Validity Code = Y (Yes)

Agency Qualifier Code = * not used
Reject Reason Code = 50 (Provider Ineligible For
Inquiries)
Follow-Up Action Code = N (Resubmission Not
Allowed)

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SE*8*4323~ Number of Included Segments = 8

Transaction Set Control Number = 4323

3.2 Example 2
Example 2 is for a patient who is the dependent of a subscriber.There are two responses
in this section. The first response is a positive response where the dependent was found.
The second response is a rejection for a provider not authorized to access the payer's
eligibility system.

3.2.1 Request
Generic request by a physician for the patient's (dependent) eligibility.
This is an example of an eligibility request from an individual provider to a payer. The
physician is inquiring if the patient (the dependent) has coverage. The request is from
Marcus Jones to the ABC Company. This example uses the Primary Search Option (see
Section 1.4.8 - Search Options) for a dependent who is the patient and is for a generic
request for Eligibility (see Section 1.4.7 - Implementation-Compliant Use of the 270/271
Transaction Set).

ST*270*1235*005010X279~ Transaction Set ID Code = 270 (Eligibility, Coverage

or Benefit Inquiry)
Transaction Set Control Number = 1235
Implementation Convention Reference =
005010X279

BHT*0022*13*10001235*20060501*1320~ Hierarchical Structure Code = 0022 (Information

Source, Information Receiver, Subscriber,
Dependent)
Transaction Set Purpose Code = 13 (Request)
Identification
Reference Identification = 10001235
Date = 20060501 (May 1, 2006)
Time = 1:20 PM

HL*1**20*1~ Hierarchical ID Number = 1

Hierarchical Parent ID Number = * not used
Hierarchical Level Code = 20 (Information Source)
Hierarchical Child Code = 1

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NM1*PR*2*ABC COMPANY*****PI* Entity Identifier Code = PR (Payer)

842610001~ Entity Type Qualifier = 2 (Non-person)
Last Name = ABC Company
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = PI (Payer
Identification)
Identification Code = 842610001

HL*2*1*21*1~ Hierarchical ID Number = 2

Hierarchical Parent ID Number = 1
Hierarchical Level Code = 21
Hierarchical Child Code = 1

NM1*1P*1*JONES*MARCUS****SV* Entity Identifier Code = 1P (Provider)

0202034~ Entity Type Qualifier = 1 (Person)
Last Name = Jones
First Name = Marcus
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = SV Service Provider
Number
Identification Code = 0202034

HL*3*2*22*1~ Hierarchical ID Number = 3

Hierarchical Parent ID Number = 2
Hierarchical Level Code = 21
Hierarchical Child Code = 1

NM1*IL*1******MI*11122333301~ Entity Identifier Code = IL (Insured or Subscriber)

Entity Type Qualifier = 1 (Person)
Last Name = * not used
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = MI (Member
Identification Number)
Identification Code = 11122333301

HL*4*3*23*0~ Hierarchical ID Number = 4

Hierarchical Parent ID Number = 3
Hierarchical Level Code = 23
Hierarchical Child Code = 0

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TRN*1*93175-012547*9877281234~ Trace Type Code = 1 (Current Transaction Trace

Number)
Reference Identification = 93175-012547
Originating Company Identifier = 9877281234
Reference Identification = * not used

NM1*03*1*SMITH*MARY~ Entity Identifier Code = 03 (Dependent)

Entity Type Qualifier = 1 (Person)
Last Name = Smith
First Name = Mary
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
* not used
Identification Code = * not used

DMG*D8*19781014~ Date Time Period Format = D8 (Date Expressed in

Format CCYYMMDD)
Date Time Period = 19781014

DTP*291*D8*20060501~ Date/Time Qualifier = 291 (Plan)

Date Time Period Format Qualifier D8 (Dates
Expressed in Format CCYYMMDD)
Date Time Period = 20060501(May 1, 2006)

EQ*30~ Service Type Code = 30 (Health Benefit Plan

Coverage

SE*15*1234~ Number of Included Segments = 15

Transaction Set Control Number = 1234

3.2.2 Response
Response to a generic request by a physician for the patient's (dependent)
eligibility.
This is an example of an eligibility response from a payer to an individual provider based
on the request in Section 3.2.1 - Request. The request is from Bone and Joint Clinic to
the ABC Company. This response illustrates the required components outlined in
Section 1.4.7 - Implementation-Compliant Use of the 270/271 Transaction Set. The
payer has indicated the patient (the dependent) has active coverage for the health plan,
the beginning date for their coverage with the plan, active coverage for all the benefits
outlined in Section 1.4.7 - Implementation-Compliant Use of the 270/271 Transaction
Set and they have a Primary Care Physician.

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ST*271*4322*005010X279~ Transaction Set ID Code = 271 (Eligibility, Coverage

or Benefit Information)
Transaction Set Control Number = 4322
Implementation Convention Reference =
005010X279

BHT*0022*11*10001235*20060501*1319~ Hierarchical Structure Code = 0022 (Information

Source, Information Receiver, Subscriber,
Dependent)
Transaction Set Purpose Code = 11 (Response)
Identification
Reference Identification = 10001235
Date = 20060501 (May 1, 2006)
Time = 1:19 PM

HL*1**20*1~ Hierarchical ID Number = 1

Hierarchical Parent ID Number = * not used
Hierarchical Level Code = 20 (Information Source)
Hierarchical Child Code = 1

NM1*PR*2*ABC COMPANY*****PI* Entity Identifier Code = PR (Payer)

842610001~ Entity Type Qualifier = 2 (Non-Person Entity)
Last Name = ABC Company
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = PI (Payer
Identification)
Identification Code = 842610001

HL*2*1*21*1~ Hierarchical ID Number = 2

Hierarchical Parent ID Number = 1
Hierarchical Level Code = 21 (Information Receiver)
Hierarchical Child Code = 1

NM1*1P*2*BONE AND JOINT CLINIC***** Entity Identifier Code = 1P (Provider)

SV*2000035~ Entity Type Qualifier = 2 (Non-Person Entity)
Last Name = Bone and Joint Clinic
First Name = * not used
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = SV (Service Provider
Number)
Identification Code = 2000035

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HL*3*2*22*1~ Hierarchical ID Number = 3

Hierarchical Parent ID Number = 2
Hierarchical Level Code = 21 (Subscriber)
Hierarchical Child Code = 1

NM1*IL*1*SMITH*JOHN****MI* Entity Identifier Code = IL (Insured or Subscriber)

123456789~ Entity Type Qualifier = 1 (Person)
Last Name = Smith
First Name = John
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = MI (Member
Identification)
Identification Code = 123456789

N3*15197 BROADWAY AVENUE*APT 215~ Address Information = 15197 BROADWAY

AVENUE
Address Information = APT 215

N4*KANSAS CITY*MO*64108~ City = KANSAS CITY

State or Prov Code = MO
Postal Code = 64108

DMG*D8*19630519*M~ Date Time Period Format = D8 (Date Expressed in

Format CCYYMMDD)
Date Time Period = 19630519
Gender Code = M (Male)

HL*4*3*23*1~ Hierarchical ID Number = 4

Hierarchical Parent ID Number = 3
Hierarchical Level Code = 23 (Dependent)
Hierarchical Child Code = 0

TRN*2*93175-012547*9877281234~ Trace Type Code = 2 (Referenced Transaction

Trace Number)
Reference Identification = 93175-012547
Originating Company Identifier = 9877281234
Reference Identification = * not used

NM1*03*1*SMITH*MARY~ Entity Identifier Code = 03 (Dependent)

Entity Type Qualifier = 1 (Person)
Last Name = Smith
First Name = Mary
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = * not used
Identification Code = * not used

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N3*15197 BROADWAY AVENUE*APT 215~ Address Information = 15197 BROADWAY

AVENUE
Address Information = APT 215

N4*KANSAS CITY*MO*64108~ City = KANSAS CITY

State or Prov Code = MO
Postal Code = 64108

DMG*D8*19981014*F~ Date Time Period Format = D8 (Date Expressed in

Format CCYYMMDD)
Date Time Period = 19981014
Gender Code = F (Female)

INS*N*19~ Yes/No Condition Or Response Code (Insured

Indicator) = N (No)
Individual Relationship Code = 19 (Child)

DTP*346*D8*20060101~ Date/Time Qualifier = 346 (Plan Begin)

Date Time Period Format Qualifier D8 (Dates
Expressed in Format CCYYMMDD)
Date Time Period = 20060101 (January 1, 2006)

EB*1**30**GOLD 123 PLAN~ Eligibility or Benefit Information Code = 1 (Active

Coverage)
Coverage Level Code = * not used
Service Type Code = 30 (Health Benefit Plan
Coverage)
Insurance Type Code = * not used
Plan Coverage Description = Gold 123 Plan

EB*L~ Eligibility or Benefit Information Code = L (Primary

Care Provider)

LS*2120~ Loop Identifier Code = 2120

NM1*P3*1*JONES*MARCUS**** Entity Identifier Code = P3 (Primary Care Provider)

SV*0202034~ Entity Type Qualifier = 1 (Person)
Last Name = Jones
First Name = Marcus
Middle Name = * not used
Name Prefix = * not used
Name Suffix = * not used
Identification Code Qualifier = SV Service Provider
Number
Identification Code = 0202034

LE*2120~ Loop Identifier Code = 2120

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EB*1**1^33^35^47^86^88^98^ Eligibility or Benefit Information Code = 1 (Active

AL^MH^UC~ Coverage)
Coverage Level Code = * not used
Service Type Code = 1 (Medical Care)
Service Type Code = 33 (Chiropractic)
Service Type Code = 35 (Dental Care)
Service Type Code = 47 (Hospital)
Service Type Code = 86 (Emergency Services)
Service Type Code = 88 (Pharmacy)
Service Type Code = 98 (Professional (Physician)
Visit - Office)
Service Type Code = AL (Vision (Optometry))
Service Type Code = MH (Mental Health)
Service Type Code = UC (Urgent Care)

EB*B**1^33^35^47^86^88^98^AL^MH^ Eligibility or Benefit Information Code = B

UC*HM*GOLD 123 PLAN*27*10*****Y~ (Co-Payment)
Coverage Level Code = * not used
Service Type Code = 1 (Medical Care)
Service Type Code = 33 (Chiropractic)
Service Type Code = 35 (Dental Care)
Service Type Code = 47 (Hospital)
Service Type Code = 86 (Emergency Services)
Service Type Code = 88 (Pharmacy)
Service Type Code = 98 (Professional (Physician)
Visit - Office)
Service Type Code = AL (Vision (Optometry))
Service Type Code = MH (Mental Health)
Service Type Code = UC (Urgent Care)
Insurance Type Code = HM (Health Management
Organization (HMO))
Plan Coverage Description = GOLD 123 PLAN
Time Period Qualifier = 27 (Visit)
Monetary Value = 10 (Dollar)
Percent = * not used
Quantity Qualifier = * not used
Quantity = * not used
Yes/No Condition Or Response Code
(Certification/Authorization Indicator) = * not used
Yes/No Condition Or Response Code (In Plan
Network Indicator) = Y (Yes – In Network)

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EB*B**1^33^35^47^86^88^98^AL^MH^UC Eligibility or Benefit Information Code = B

*HM*GOLD 123 PLAN*27*30*****N~ (Co-Payment)
Coverage Level Code = * not used
Service Type Code = 1 (Medical Care)
Service Type Code = 33 (Chiropractic)
Service Type Code = 35 (Dental Care)
Service Type Code = 47 (Hospital)
Service Type Code = 86 (Emergency Services)
Service Type Code = 88 (Pharmacy)
Service Type Code = 98 (Professional (Physician)
Visit - Office)
Service Type Code = AL (Vision (Optometry))
Service Type Code = MH (Mental Health)
Service Type Code = UC (Urgent Care)
Insurance Type Code = HM (Health Management
Organization (HMO))
Plan Coverage Description = GOLD 123 PLAN
Time Period Qualifier = 27 (Visit)
Monetary Value = 30 (Dollar)
Percent = * not used
Quantity Qualifier = * not used
Quantity = * not used
Yes/No Condition Or Response Code
(Certification/Authorization Indicator) = * not used
Yes/No Condition Or Response Code (In Plan
Network Indicator) = N (No – Out of Network)

SE*28*4322~ Number of Included Segments = 28

Transaction Set Control Number = 4322

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A External Code Sources

A.1 External Code Sources
This Implementation Guide uses Code Sources belonging to the Centers for Medicare
and Medicaid Services (CMS), formerly known as the Health Care Finance Administration
(HCFA). Several of these code source's name and/or address information has been
revised since the publication of the underlying X12 Standard. The entries in this appendix
reflect the current Code Source name and/or address. The affected Code Sources are:

130 Health Care Financing Administration Common Procedural Coding System

237 Place of Service from Health Care Financing Administration Claim Form
537 Health Care Financing Administration National Provider Identifier
540 Health Care Financing Administration PlanID

5 Countries, Currencies and Funds

SIMPLE DATA ELEMENT/CODE REFERENCES
26, 100, 1715, 66/38, 235/CH, 955/SP

SOURCE
Codes for Representation of Names of Countries, ISO 3166-(Latest Release)

Codes for Representation of Currencies and Funds, ISO 4217-(Latest Release)

AVAILABLE FROM
American National Standards Institute
25 West 43rd Street, 4th Floor
New York, NY 10036

ABSTRACT
Part 1 (Country codes) of the ISO 3166 international standard establishes codes that
represent the current names of countries, dependencies, and other areas of special
geopolitical interest, on the basis of lists of country names obtained from the United
Nations. Part 2 (Country subdivision codes) establishes a code that represents the
names of the principal administrative divisions, or similar areas, of the countries, etc.
included in Part 1. Part 3 (Codes for formerly used names of countries) establishes a
code that represents non-current country names, i.e., the country names deleted from
ISO 3166 since its first publication in 1974. Most currencies are those of the geopolitical

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entities that are listed in ISO 3166 Part 1, Codes for the Representation of Names of
Countries. The code may be a three-character alphabetic or three-digit numeric. The
two leftmost characters of the alphabetic code identify the currency authority to which
the code is assigned (using the two character alphabetic code from ISO 3166 Part 1, if
applicable). The rightmost character is a mnemonic derived from the name of the major
currency unit or fund. For currencies not associated with a single geographic entity, a
specially-allocated two-character alphabetic code, in the range XA to XZ identifies the
currency authority. The rightmost character is derived from the name of the geographic
area concerned, and is mnemonic to the extent possible. The numeric codes are identical
to those assigned to the geographic entities listed in ISO 3166 Part 1. The range 950-998
is reserved for identification of funds and currencies not associated with a single entity
listed in ISO 3166 Part 1.

22 States and Provinces

SIMPLE DATA ELEMENT/CODE REFERENCES
156, 66/SJ, 235/A5, 771/009

SOURCE
U.S. Postal Service or

Canada Post or
Bureau of Transportation Statistics

AVAILABLE FROM
The U.S. state codes may be obtained from:
U.S. Postal Service
National Information Data Center
P.O. Box 2977
Washington, DC 20013
www.usps.gov
The Canadian province codes may be obtained from:
http://www.canadapost.ca
The Mexican state codes may be obtained from:
www.bts.gov/ntda/tbscd/mex-states.html

ABSTRACT
Provides names, abbreviations, and two character codes for the states, provinces and
sub-country divisions as defined by the appropriate government agency of the United
States, Canada, and Mexico.

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51 ZIP Code
SIMPLE DATA ELEMENT/CODE REFERENCES
116, 66/16, 309/PQ, 309/PR, 309/PS, 771/010

SOURCE
National ZIP Code and Post Office Directory, Publication 65

The USPS Domestic Mail Manual

AVAILABLE FROM
U.S Postal Service
Washington, DC 20260
New Orders
Superintendent of Documents
P.O. Box 371954
Pittsburgh, PA 15250-7954

ABSTRACT
The ZIP Code is a geographic identifier of areas within the United States and its territories
for purposes of expediting mail distribution by the U.S. Postal Service. It is five or nine
numeric digits. The ZIP Code structure divides the U.S. into ten large groups of states.
The leftmost digit identifies one of these groups. The next two digits identify a smaller
geographic area within the large group. The two rightmost digits identify a local delivery
area. In the nine-digit ZIP Code, the four digits that follow the hyphen further subdivide
the delivery area. The two leftmost digits identify a sector which may consist of several
large buildings, blocks or groups of streets. The rightmost digits divide the sector into
segments such as a street, a block, a floor of a building, or a cluster of mailboxes. The
USPS Domestics Mail Manual includes information on the use of the new 11-digit zip
code.

130 Healthcare Common Procedural Coding System

SIMPLE DATA ELEMENT/CODE REFERENCES
235/HC, 1270/BO, 1270/BP

SOURCE
Healthcare Common Procedural Coding System

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AVAILABLE FROM
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

ABSTRACT
HCPCS is Centers for Medicare & Medicaid Service's (CMS) coding scheme to group
procedures performed for payment to providers.

131 International Classification of Diseases, 9th

Revision, Clinical Modification (ICD-9-CM)
SIMPLE DATA ELEMENT/CODE REFERENCES
128/ICD, 235/DX, 235/ID, 1270/BF, 1270/BJ, 1270/BK, 1270/BN, 1270/BQ, 1270/BR,
1270/DD, 1270/PR, 1270/SD, 1270/TD, 1270/AAU, 1270/AAV, 1270/AAX

SOURCE
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM),
Volumes I, II and III

AVAILABLE FROM
Superintendent of Documents
U.S. Government Printing Office
P.O. Box 371954
Pittsburgh, PA 15250

ABSTRACT
The International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM), Volumes I, II (diagnoses) and III (procedures) describes the classification
of morbidity and mortality information for statistical purposes and for the indexing of
healthcare records by diseases and procedures.

133 Current Procedural Terminology (CPT) Codes

SIMPLE DATA ELEMENT/CODE REFERENCES
128/CPT, 235/CJ, 1270/BS, 1270/AAW

SOURCE
Physicians' Current Procedural Terminology (CPT) Manual

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AVAILABLE FROM
Order Department
American Medical Association
515 North State Street
Chicago, IL 60610

ABSTRACT
A listing of descriptive terms and identifying codes for reporting medical services and
procedures performed by physicians.

135 American Dental Association

SIMPLE DATA ELEMENT/CODE REFERENCES
1361, 235/AD, 1270/JO, 1270/JP, 1270/TQ, 1270/AAY

SOURCE
Current Dental Terminology (CDT) Manual

AVAILABLE FROM
Salable Materials
American Dental Association
211 East Chicago Avenue
Chicago, IL 60611-2678

ABSTRACT
The CDT manual contains the American Dental Association's codes for dental procedures
and nomenclature and is the accepted set of numeric codes and descriptive terms for
reporting dental treatments and descriptors.

206 Government Bill of Lading Office Code

SIMPLE DATA ELEMENT/CODE REFERENCES
309

SOURCE
Defense Traffic Management Regulation (DTMR), Appendix I - Government Bill of Lading
Codes

AVAILABLE FROM
Military Traffic Management Command (MTMC)

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Attn: Programs and Systems Support (MTIN-P)

5611 Columbia Pike
Falls Church, VA 22041-5050

ABSTRACT
Defines the regulations for managing the transportation of goods owned or purchased
by the Department of Defense.

237 Place of Service Codes for Professional Claims

SIMPLE DATA ELEMENT/CODE REFERENCES
1332/B

SOURCE
Place of Service Codes for Professional Claims

AVAILABLE FROM
Centers for Medicare and Medicaid Services
CMSO, Mail Stop S2-01-16
7500 Security Blvd
Baltimore, MD 21244-1850

ABSTRACT
The Centers for Medicare and Medicaid Services develops place of service codes to
identify the location where health care services are performed.

240 National Drug Code by Format

SIMPLE DATA ELEMENT/CODE REFERENCES
235/N1, 235/N2, 235/N3, 235/N4, 235/N5, 235/N6, 1270/NDC

SOURCE
Drug Establishment Registration and Listing Instruction Booklet

AVAILABLE FROM
Federal Drug Listing Branch HFN-315
5600 Fishers Lane
Rockville, MD 20857

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ABSTRACT
Publication includes manufacturing and labeling information as well as drug packaging
sizes.

284 Nature of Injury Code

SIMPLE DATA ELEMENT/CODE REFERENCES
1270/GR, 1270/NI

SOURCE
TABLE 8, DCI 25

AVAILABLE FROM
National Council on Compensation Insurance
E-Commerce
750 Park of Commerce Drive
Boca Raton, FL 33487

ABSTRACT
This publication describes nature of injury. The nature of injury or illness classification
identifies the injury or illness in terms of its principal physical characteristics.

307 National Council for Prescription Drug Programs

Pharmacy Number
SIMPLE DATA ELEMENT/CODE REFERENCES
128/D3

SOURCE
National Council for Prescription Drug Programs (NCPDP) Provider Number Database
and Listing

AVAILABLE FROM
National Council for Prescription Drug Programs (NCPDP)
9240 East Raintree Drive
Scottsdale, AZ 85260

ABSTRACT
A unique number assigned in the U.S. and its territories to individual clinic, hospital,
chain, and independent pharmacy and dispensing physician locations that conduct

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business by billing third-party and dispensing physician locations that conduct business
by billing third-party drug benefit payers. The National Council for Prescription Drug
Programs (NCPDP) maintains this database. The NCPDP Provider Number is a
seven-digit number with the following format SSNNNNC, where SS=NCPDP assigned
state code number, NNNN=sequential numbering scheme assigned to pharmacy
locations, and C=check digit caluculate by algorithm from previous six digits.

407 Occupational Injury and Illness Classification

Manual
SIMPLE DATA ELEMENT/CODE REFERENCES
559/LB, 1270/BT, 1270/BU, 1270/EK, 1270/GS, 1270/GU, 1270/GW, 1270/NI, 1270/PB,
1270/SJ, 1270/SL

SOURCE
U.S. Department of Labor

AVAILABLE FROM
Bureau of Labor Statistics
Office of Safety, Health, and Working Conditions
Room 3180
Postal Square Building
2 Massachusetts Ave., N.E.
Washington, DC 20212

ABSTRACT
The Occupational Injury and Illness Classification Manual (OI&ICM) provides a
classification system for use in coding the case characteristics of injuries and illnesses
in the Occupational Safety and Health (OSH) program and the Census of Fatal
Occupational Injuries (CFOI) program. This manual contains the rules of selection, code
descriptions, code titles, and indices, for the following code structures: Nature of Injury
or Illness, Part of Body Affected, Source of Injury or Illness, Event or Exposure, and
Secondary Source of Injury or Illness.

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513 Home Infusion EDI Coalition (HIEC)

Product/Service Code List
SIMPLE DATA ELEMENT/CODE REFERENCES
235/IV, 1270/HO

SOURCE
Home Infusion EDI Coalition (HIEC) Coding System

AVAILABLE FROM
HIEC Chairperson
HIBCC (Health Industry Business Communications Council)
5110 North 40th Street
Suite 250
Phoenix, AZ 85018

ABSTRACT
This list contains codes identifying home infusion therapy products/services.

537 Centers for Medicare and Medicaid Services

National Provider Identifier
SIMPLE DATA ELEMENT/CODE REFERENCES
66/XX, 128/HPI

SOURCE
National Provider System

AVAILABLE FROM
Centers for Medicare and Medicaid Services
Office of Financial Management
Division of Provider/Supplier Enrollment
C4-10-07
7500 Security Boulevard
Baltimore, MD 21244-1850

ABSTRACT
The Centers for Medicare and Medicaid Services is developing the National Provider
Identifier (NPI), which has been proposed as the standard unique identifier for each

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health care provider under the Health Insurance Portability and Accountability Act of
1996.

540 Centers for Medicare and Medicaid Services

PlanID
SIMPLE DATA ELEMENT/CODE REFERENCES
66/XV, 128/ABY

SOURCE
PlanID Database

AVAILABLE FROM
Centers for Medicare and Medicaid Services
Center of Beneficiary Services, Membership Operations Group
Division of Benefit Coordination
S1-05-06
7500 Security Boulevard
Baltimore, MD 21244-1850

ABSTRACT
The Centers for Medicare and Medicaid Services has joined with other payers to develop
a unique national payer identification number. The Centers for Medicare and Medicaid
Services is the authorizing agent for enumerating payers through the services of a PlanID
Registrar. It may also be used by other payers on a voluntary basis.

682 Health Care Provider Taxonomy

SIMPLE DATA ELEMENT/CODE REFERENCES
128/PXC, 1270/68

SOURCE
The National Uniform Claim Committee

AVAILABLE FROM
The National Uniform Claim Committee
c/o American Medical Association
515 North State Street
Chicago, IL 60610

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ABSTRACT
Codes defining the health care service provider type, classification, and area of
specialization.

844 Eligibility Category

SIMPLE DATA ELEMENT/CODE REFERENCES
128/MRC

SOURCE
Department of Defense Instruction (DoDI) 1000.13

Dependent Information - Block 35 Relationship

AVAILABLE FROM
Office of the Deputy Undersecretary of Defense for Program Integration
Department of Defense
4000 Defense Pentagon
Washington, DC 20301-4000

ABSTRACT
The Department of Defense Eligibility Category expresses the eligibility category of the
member to properly administer health benefits and coverage.

896 International Classification of Diseases, 10th

Revision, Procedure Coding System (ICD-10-PCS)
SIMPLE DATA ELEMENT/CODE REFERENCES
235/IP, 1270/BBQ, 1270/BBR

SOURCE
International Classification of Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS)

AVAILABLE FROM
CMM, HAPG, Division of Acute Care
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

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ABSTRACT
The International Classification of Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS), describes the classification of inpatient procedures for statistical purposes
and for the indexing of healthcare records by procedures.

897 International Classification of Diseases, 10th

Revision, Clinical Modification (ICD-10-CM)
SIMPLE DATA ELEMENT/CODE REFERENCES
235/DC, 1270/ABF, 1270/ABJ, 1270/ABK, 1270/ABN, 1270/ABU, 1270/ABV, 1270/ADD,
1270/APR, 1270/ASD, 1270/ATD

SOURCE
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

AVAILABLE FROM
OCD/Classifications and Public Health Data Standards
National Center for Health Statistics
3311 Toledo Road
Hyattsville, MD 20782

ABSTRACT
The International Classicication of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM), describes the classification of morbidity and mortality information for
statistical purposes and for the indexing of healthcare records by diseases.

932 Universal Postal Codes

SIMPLE DATA ELEMENT/CODE REFERENCES
116

SOURCE
Universal Postal Union website

AVAILABLE FROM
International Bureau of the Universal Postal Union
POST*CODE
Case postale 13
3000 BERNE 15 Switzerland

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ABSTRACT
The postcode is the fundamental, essential element of an address. A unique, universal
identifier, it unambiguously identifies the addressee's locality and assists in the
transmission and sorting of mail items. At present, 105 UPU member countries use
postcodes as part of their addressing systems.

DOD1 Military Rank and Health Care Service Region

SIMPLE DATA ELEMENT/CODE REFERENCES
309/RJ

SOURCE
Military Health Systems Functional Area Manual - Data

AVAILABLE FROM
Health Affairs Functional Data Administrator
TRICARE Management Activity
Information Management Technology and Reengineering, FI and DA
5111 Leesburg Pike Suite 810
Falls Church, VA 22041-3206

ABSTRACT
(region): The Department of Defense Health Care Service Region code indicates the
specific domestic or foreign regions that administer health benefits for military personnel.

DOD2 Paygrade
SIMPLE DATA ELEMENT/CODE REFERENCES
1038

SOURCE
Department of Defense Instruction (DODI) 1000.13
Sponsor Information - Block 7
Rank / Paygrade

AVAILABLE FROM
Office of the Deputy Undersecretary of Defense for Program Integration
Department of Defense
4000 Defense Pentagon
Washington, DC 20301-4000

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ABSTRACT
The Department of Defense Rank and Paygrade expresses the rank and pay-grade
code for military personnel.

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B Nomenclature
B.1 ASC X12 Nomenclature
B.1.1 Interchange and Application Control Structures
Appendix B is provided as a reference to the X12 syntax, usage, and related information.
It is not a full statement of Interchange and Control Structure rules. The full X12
Interchange and Control Structures and other rules (X12.5, X12.6, X12.59, X12
dictionaries, other X12 standards and official documents) apply unless specifically
modified in the detailed instructions of this implementation guide (see
Section B.1.1.3.1.2 - Decimal for an example of such a modification).

B.1.1.1 Interchange Control Structure

The transmission of data proceeds according to very strict format rules to ensure the
integrity and maintain the efficiency of the interchange. Each business grouping of data
is called a transaction set. For instance, a group of benefit enrollments sent from a
sponsor to a payer is considered a transaction set.

Each transaction set contains groups of logically related data in units called segments.
For instance, the N4 segment used in the transaction set conveys the city, state, ZIP
Code, and other geographic information. A transaction set contains multiple segments,
so the addresses of the different parties, for example, can be conveyed from one
computer to the other. An analogy would be that the transaction set is like a freight train;
the segments are like the train's cars; and each segment can contain several data
elements the same as a train car can hold multiple crates.

The sequence of the elements within one segment is specified by the ASC X12 standard
as well as the sequence of segments in the transaction set. In a more conventional
computing environment, the segments would be equivalent to records, and the elements
equivalent to fields.

Similar transaction sets, called "functional groups," can be sent together within a
transmission. Each functional group is prefaced by a group start segment; and a functional
group is terminated by a group end segment. One or more functional groups are prefaced
by an interchange header and followed by an interchange trailer.
Figure B.1 - Transmission Control Schematic, illustrates this interchange control.

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Figure B.1 - Transmission Control Schematic

The interchange header and trailer segments envelop one or more functional groups or
interchange-related control segments and perform the following functions:

1. Define the data element separators and the data segment terminator.
2. Identify the sender and receiver.
3. Provide control information for the interchange.
4. Allow for authorization and security information.

B.1.1.2 Application Control Structure Definitions and Concepts

B.1.1.2.1 Basic Structure
A data element corresponds to a data field in data processing terminology. A data
segment corresponds to a record in data processing terminology. The data segment

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begins with a segment ID and contains related data elements. A control segment has
the same structure as a data segment; the distinction is in the use. The data segment
is used primarily to convey user information, but the control segment is used primarily
to convey control information and to group data segments.

B.1.1.2.2 Basic Character Set

The section that follows is designed to have representation in the common character
code schemes of EBCDIC, ASCII, and CCITT International Alphabet 5. The ASC X12
standards are graphic-character-oriented; therefore, common character encoding
schemes other than those specified herein may be used as long as a common mapping
is available. Because the graphic characters have an implied mapping across character
code schemes, those bit patterns are not provided here.

The basic character set of this standard, shown in Table B.1 - Basic Character Set,
includes those selected from the uppercase letters, digits, space, and special characters
as specified below.

Table B.1 - Basic Character Set

A...Z 0...9 ! & ( ) + *

, - . / : ; ? = (space)

B.1.1.2.3 Extended Character Set

An extended character set may be used by negotiation between the two parties and
includes the lowercase letters and other special characters as specified in
Table B.2 - Extended Character Set.

Table B.2 - Extended Character Set

a...z % ~ @ [ ] _ {

} \ | < > # $

Note that the extended characters include several character codes that have multiple
graphical representations for a specific bit pattern. The complete list appears in other
standards such as CCITT S.5. Use of the USA graphics for these codes presents no
problem unless data is exchanged with an international partner. Other problems, such
as the translation of item descriptions from English to French, arise when exchanging
data with an international partner, but minimizing the use of codes with multiple graphics
eliminates one of the more obvious problems.

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For implementations compliant with this guide, either the entire extended character set
must be acceptable, or the entire extended character set must not be used. In the
absence of a specific trading partner agreement to the contrary, trading partners will
assume that the extended character set is acceptable. Use of the extended character
set allows the use of the "@" character in email addresses within the PER segment.
Users should note that characters in the extended character set, as well as the basic
character set, may be used as delimiters only when they do not occur in the data as
stated in Section B.1.1.2.4.1 - Base Control Set.

B.1.1.2.4 Control Characters

Two control character groups are specified; they have restricted usage. The common
notation for these groups is also provided, together with the character coding in three
common alphabets. In Table B.3 - Base Control Set, the column IA5 represents CCITT
V.3 International Alphabet 5.

B.1.1.2.4.1 Base Control Set

The base control set includes those characters that will not have a disruptive effect on
most communication protocols. These are represented by:

Table B.3 - Base Control Set

NOTATION NAME EBCDIC ASCII IA5

BEL bell 2F 07 07

HT horizontal tab 05 09 09

LF line feed 25 0A 0A

VT vertical tab 0B 0B 0B

FF form feed 0C 0C 0C

CR carriage return 0D 0D 0D

FS file separator 1C 1C 1C

GS group separator 1D 1D 1D

RS record separator 1E 1E 1E

US unit separator 1F 1F 1F

NL new line 15

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The Group Separator (GS) may be an exception in this set because it is used in the
3780 communications protocol to indicate blank space compression.

B.1.1.2.4.2 Extended Control Set

The extended control set includes those that may have an effect on a transmission
system. These are shown in Table B.4 - Extended Control Set.

Table B.4 - Extended Control Set

NOTATION NAME EBCDIC ASCII IA5

SOH start of header 01 01 01

STX start of text 02 02 02

ETX end of text 03 03 03

EOT end of transmission 37 04 04

ENQ enquiry 2D 05 05

ACK acknowledge 2E 06 06

DC1 device control 1 11 11 11

DC2 device control 2 12 12 12

DC3 device control 3 13 13 13

DC4 device control 4 3C 14 14

NAK negative acknowledge 3D 15 15

SYN synchronous idle 32 16 16

ETB end of block 26 17 17

B.1.1.2.5 Delimiters
A delimiter is a character used to separate two data elements or component elements
or to terminate a segment. The delimiters are an integral part of the data.

Delimiters are specified in the interchange header segment, ISA. The ISA segment can
be considered in implementations compliant with this guide (see Appendix C, ISA
Segment Note 1) to be a 105 byte fixed length record, followed by a segment terminator.
The data element separator is byte number 4; the repetition separator is byte number

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83; the component element separator is byte number 105; and the segment terminator
is the byte that immediately follows the component element separator.

Once specified in the interchange header, the delimiters are not to be used in a data
element value elsewhere in the interchange. For consistency, this implementation guide
uses the delimiters shown in Table B.5 - Delimiters, in all examples of EDI transmissions.

Table B.5 - Delimiters

CHARACTER NAME DELIMITER

* Asterisk Data Element Separator

^ Carat Repetition Separator

: Colon Component Element Separator

~ Tilde Segment Terminator

The delimiters above are for illustration purposes only and are not specific
recommendations or requirements. Users of this implementation guide should be aware
that an application system may use some valid delimiter characters within the application
data. Occurrences of delimiter characters in transmitted data within a data element will
result in errors in translation. The existence of asterisks (*) within transmitted application
data is a known issue that can affect translation software.

B.1.1.3 Business Transaction Structure Definitions and Concepts

The ASC X12 standards define commonly used business transactions (such as a health
care claim) in a formal structure called "transaction sets." A transaction set is composed
of a transaction set header control segment, one or more data segments, and a
transaction set trailer control segment. Each segment is composed of the following:

• A unique segment ID
• One or more logically related data elements each preceded by a data element separator
• A segment terminator

B.1.1.3.1 Data Element

The data element is the smallest named unit of information in the ASC X12 standard.
Data elements are identified as either simple or component. A data element that occurs
as an ordinally positioned member of a composite data structure is identified as a
component data element. A data element that occurs in a segment outside the defined
boundaries of a composite data structure is identified as a simple data element. The

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distinction between simple and component data elements is strictly a matter of context
because a data element can be used in either capacity.

Data elements are assigned a unique reference number. Each data element has a name,
description, type, minimum length, and maximum length. For ID type data elements, this
guide provides the applicable ASC X12 code values and their descriptions or references
where the valid code list can be obtained.

A simple data element within a segment may have an attribute indicating that it may
occur once or a specific number of times more than once. The number of permitted
repeats are defined as an attribute in the individual segment where the repeated data
element occurs.

Each data element is assigned a minimum and maximum length. The length of the data
element value is the number of character positions used except as noted for numeric,
decimal, and binary elements.

The data element types shown in Table B.6 - Data Element Types, appear in this
implementation guide.

Table B.6 - Data Element Types

SYMBOL TYPE

Nn Numeric

R Decimal

ID Identifier

AN String

DT Date

TM Time

B Binary

The data element minimum and maximum lengths may be restricted in this implementation
guide for a compliant implementation. Such restrictions may occur by virtue of the allowed
qualifier for the data element or by specific instructions regarding length or format as
stated in this implementation guide.

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B.1.1.3.1.1 Numeric
A numeric data element is represented by one or more digits with an optional leading
sign representing a value in the normal base of 10. The value of a numeric data element
includes an implied decimal point. It is used when the position of the decimal point within
the data is permanently fixed and is not to be transmitted with the data.

This set of guides denotes the number of implied decimal positions. The representation
for this data element type is "Nn" where N indicates that it is numeric and n indicates
the number of decimal positions to the right of the implied decimal point.

If n is 0, it need not appear in the specification; N is equivalent to N0. For negative values,
the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus
sign (+) must not be transmitted.

EXAMPLE
A transmitted value of 1234, when specified as numeric type N2, represents a value of
12.34.

Leading zeros must be suppressed unless necessary to satisfy a minimum length

requirement. The length of a numeric type data element does not include the optional
sign.

B.1.1.3.1.2 Decimal
A decimal data element may contain an explicit decimal point and is used for numeric
values that have a varying number of decimal positions. This data element type is
represented as "R."

The decimal point always appears in the character stream if the decimal point is at any
place other than the right end. If the value is an integer (decimal point at the right end)
the decimal point must be omitted. For negative values, the leading minus sign (-) is
used. Absence of a sign indicates a positive value. The plus sign (+) must not be
transmitted.

Leading zeros must be suppressed unless necessary to satisfy a minimum length

requirement. Trailing zeros following the decimal point must be suppressed unless
necessary to indicate precision. The use of triad separators (for example, the commas
in 1,000,000) is expressly prohibited. The length of a decimal type data element does
not include the optional leading sign or decimal point.

EXAMPLE
A transmitted value of 12.34 represents a decimal value of 12.34.

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While the ASC X12 standard supports usage of exponential notation, this guide prohibits
that usage.

For implementation of this guide under the rules promulgated under the Health Insurance
Portability and Accountability Act (HIPAA), decimal data elements in Data Element 782
(Monetary Amount) will be limited to a maximum length of 10 characters including reported
or implied places for cents (implied value of 00 after the decimal point). Note the statement
in the preceding paragraph that the decimal point and leading sign, if sent, are not part
of the character count.

EXAMPLE
For implementations mandated under HIPAA rules:

• The following transmitted value represents the largest positive dollar amount that can
be sent: 99999999.99
• The following transmitted value is the longest string of characters that can be sent
representing whole dollars: 99999999
• The following transmitted value is the longest string of characters that can be sent
representing negative dollars and cents: -99999999.99
• The following transmitted value is the longest string of characters that can be sent
representing negative whole dollars: -99999999

B.1.1.3.1.3 Identifier
An identifier data element always contains a value from a predefined list of codes that
is maintained by the ASC X12 Committee or some other body recognized by the
Committee. Trailing spaces must be suppressed unless they are necessary to satisfy a
minimum length. An identifier is always left justified. The representation for this data
element type is "ID."

B.1.1.3.1.4 String
A string data element is a sequence of any characters from the basic or extended
character sets. The string data element must contain at least one non-space character.
The significant characters shall be left justified. Leading spaces, when they occur, are
presumed to be significant characters. Trailing spaces must be suppressed unless they
are necessary to satisfy a minimum length. The representation for this data element
type is "AN."

B.1.1.3.1.5 Date
A date data element is used to express the standard date in either YYMMDD or
CCYYMMDD format in which CC is the first two digits of the calendar year, YY is the
last two digits of the calendar year, MM is the month (01 to 12), and DD is the day in the

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month (01 to 31). The representation for this data element type is "DT." Users of this
guide should note that all dates within transactions are 8-character dates (millennium
compliant) in the format CCYYMMDD. The only date data element that is in format
YYMMDD is the Interchange Date data element in the ISA segment and the TA1 segment
where the century is easily determined because of the nature of an interchange header.

B.1.1.3.1.6 Time
A time data element is used to express the ISO standard time HHMMSSd..d format in
which HH is the hour for a 24 hour clock (00 to 23), MM is the minute (00 to 59), SS is
the second (00 to 59) and d..d is decimal seconds. The representation for this data
element type is "TM." The length of the data element determines the format of the
transmitted time.

EXAMPLE
Transmitted data elements of four characters denote HHMM. Transmitted data elements
of six characters denote HHMMSS.

B.1.1.3.1.7 Binary
The binary data element is any sequence of octets ranging in value from binary 00000000
to binary 11111111. This data element type has no defined maximum length. Actual
length is specified by the immediately preceding data element. Within the body of a
transaction set (from ST to SE) implemented according to this technical report, the binary
data element type is only used in the segments Binary Data Segment BIN, and Binary
Data Structure BDS. Within those segments, Data Element 785 Binary Data is a string
of octets which can assume any binary pattern from hexadecimal 00 to FF, and can be
used to send text as well as coded data, including data from another application in its
native format. The binary data type is also used in some control and security structures.

Not all transaction sets use the Binary Data Segment BIN or Binary Data Structure BDS.

B.1.1.3.2 Repeating Data Elements

Simple or composite data elements within a segment can be designated as repeating
data elements. Repeating data elements are adjacent data elements that occur up to a
number of times specified in the standard as number of repeats. The implementation
guide may also specify the number of repeats of a repeating data element in a specific
location in the transaction that are permitted in a compliant implementation. Adjacent
occurrences of the same repeating simple data element or composite data structure in
a segment shall be separated by a repetition separator.

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B.1.1.3.3 Composite Data Structure

The composite data structure is an intermediate unit of information in a segment.
Composite data structures are composed of one or more logically related simple data
elements, each, except the last, followed by a sub-element separator. The final data
element is followed by the next data element separator or the segment terminator. Each
simple data element within a composite is called a component.

Each composite data structure has a unique four-character identifier, a name, and a
purpose. The identifier serves as a label for the composite. A composite data structure
can be further defined through the use of syntax notes, semantic notes, and comments.
Each component within the composite is further characterized by a reference designator
and a condition designator. The reference designators and the condition designators
are described in Section B.1.1.3.8 - Reference Designator and
Section B.1.1.3.9 - Condition Designator.

A composite data structure within a segment may have an attribute indicating that it may
occur once or a specific number of times more than once. The number of permitted
repeats are defined as an attribute in the individual segment where the repeated
composite data structure occurs.

B.1.1.3.4 Data Segment

The data segment is an intermediate unit of information in a transaction set. In the data
stream, a data segment consists of a segment identifier, one or more composite data
structures or simple data elements each preceded by a data element separator and
succeeded by a segment terminator.

Each data segment has a unique two- or three-character identifier, a name, and a
purpose. The identifier serves as a label for the data segment. A segment can be further
defined through the use of syntax notes, semantic notes, and comments. Each simple
data element or composite data structure within the segment is further characterized by
a reference designator and a condition designator.

B.1.1.3.5 Syntax Notes

Syntax notes describe relational conditions among two or more data segment units within
the same segment, or among two or more component data elements within the same
composite data structure. For a complete description of the relational conditions, See
Section B.1.1.3.9 - Condition Designator.

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B.1.1.3.6 Semantic Notes

Simple data elements or composite data structures may be referenced by a semantic
note within a particular segment. A semantic note provides important additional
information regarding the intended meaning of a designated data element, particularly
a generic type, in the context of its use within a specific data segment. Semantic notes
may also define a relational condition among data elements in a segment based on the
presence of a specific value (or one of a set of values) in one of the data elements.

B.1.1.3.7 Comments
A segment comment provides additional information regarding the intended use of the
segment.

B.1.1.3.8 Reference Designator

Each simple data element or composite data structure in a segment is provided a
structured code that indicates the segment in which it is used and the sequential position
within the segment.The code is composed of the segment identifier followed by a two-digit
number that defines the position of the simple data element or composite data structure
in that segment.

For purposes of creating reference designators, the composite data structure is viewed
as the hierarchical equal of the simple data element. Each component data element in
a composite data structure is identified by a suffix appended to the reference designator
for the composite data structure of which it is a member. This suffix is prefixed with a
hyphen and defines the position of the component data element in the composite data
structure.

EXAMPLE

• The first simple element of the CLP segment would be identified as CLP01.
• The first position in the SVC segment is occupied by a composite data structure that
contains seven component data elements, the reference designator for the second
component data element would be SVC01-02.

B.1.1.3.9 Condition Designator

This section provides information about X12 standard conditions designators. It is provided
so that users will have information about the general standard. Implementation guides
may impose other conditions designators. See implementation guide section 2.1
Presentation Examples for detailed information about the implementation guide Industry
Usage requirements for compliant implementation.

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Data element conditions are of three types: mandatory, optional, and relational. They
define the circumstances under which a data element may be required to be present or
not present in a particular segment.

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Table B.7 - Condition Designator

DESIGNATOR DESCRIPTION

M- Mandatory The designation of mandatory is absolute in the sense that there is

no dependency on other data elements. This designation may apply
to either simple data elements or composite data structures. If the
designation applies to a composite data structure, then at least one
value of a component data element in that composite data structure
shall be included in the data segment.

O- Optional The designation of optional means that there is no requirement for

a simple data element or composite data structure to be present in
the segment. The presence of a value for a simple data element or
the presence of value for any of the component data elements of a
composite data structure is at the option of the sender.

X- Relational Relational conditions may exist among two or more simple data
elements within the same data segment based on the presence or
absence of one of those data elements (presence means a data
element must not be empty). Relational conditions are specified by
a condition code (see table below) and the reference designators of
the affected data elements. A data element may be subject to more
than one relational condition.

The definitions for each of the condition codes used within syntax
notes are detailed below:

CONDITION DEFINITION
CODE

P- Paired or If any element specified in the relational condition

Multiple is present, then all of the elements specified must
be present.

R- Required At least one of the elements specified in the

condition must be present.

E- Exclusion Not more than one of the elements specified in the

condition may be present.

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DESIGNATOR DESCRIPTION

C- Conditional If the first element specified in the condition is

present, then all other elements must be present.
However, any or all of the elements not specified
as the first element in the condition may appear
without requiring that the first element be present.
The order of the elements in the condition does not
have to be the same as the order of the data
elements in the data segment.

L- List If the first element specified in the condition is

Conditional present, then at least one of the remaining elements
must be present. However, any or all of the
elements not specified as the first element in the
condition may appear without requiring that the first
element be present. The order of the elements in
the condition does not have to be the same as the
order of the data elements in the data segment.

B.1.1.3.10 Absence of Data

Any simple data element that is indicated as mandatory must not be empty if the segment
is used. At least one component data element of a composite data structure that is
indicated as mandatory must not be empty if the segment is used. Optional simple data
elements and/or composite data structures and their preceding data element separators
that are not needed must be omitted if they occur at the end of a segment. If they do not
occur at the end of the segment, the simple data element values and/or composite data
structure values may be omitted. Their absence is indicated by the occurrence of their
preceding data element separators, in order to maintain the element's or structure's
position as defined in the data segment.

Likewise, when additional information is not necessary within a composite, the composite
may be terminated by providing the appropriate data element separator or segment
terminator.

If a segment has no data in any data element within the segment (an "empty" segment),
that segment must not be sent.

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B.1.1.3.11 Control Segments

A control segment has the same structure as a data segment, but it is used for transferring
control information rather than application information.

B.1.1.3.11.1 Loop Control Segments

Loop control segments are used only to delineate bounded loops. Delineation of the
loop shall consist of the loop header (LS segment) and the loop trailer (LE segment).
The loop header defines the start of a structure that must contain one or more iterations
of a loop of data segments and provides the loop identifier for this loop. The loop trailer
defines the end of the structure. The LS segment appears only before the first occurrence
of the loop, and the LE segment appears only after the last occurrence of the loop.
Unbounded looping structures do not use loop control segments.

B.1.1.3.11.2 Transaction Set Control Segments

The transaction set is delineated by the transaction set header (ST segment) and the
transaction set trailer (SE segment). The transaction set header identifies the start and
identifier of the transaction set. The transaction set trailer identifies the end of the
transaction set and provides a count of the data segments, which includes the ST and
SE segments.

B.1.1.3.11.3 Functional Group Control Segments

The functional group is delineated by the functional group header (GS segment) and
the functional group trailer (GE segment).The functional group header starts and identifies
one or more related transaction sets and provides a control number and application
identification information. The functional group trailer defines the end of the functional
group of related transaction sets and provides a count of contained transaction sets.

B.1.1.3.11.4 Relations among Control Segments

The control segment of this standard must have a nested relationship as is shown and
annotated in this subsection. The letters preceding the control segment name are the
segment identifier for that control segment. The indentation of segment identifiers shown
below indicates the subordination among control segments.

GS Functional Group Header, starts a group of related transaction sets.

ST Transaction Set Header, starts a transaction set.
LS Loop Header, starts a bounded loop of data segments but is not part of the
loop.
LS Loop Header, starts an inner, nested, bounded loop.
LE Loop Trailer, ends an inner, nested bounded loop.

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LE Loop Trailer, ends a bounded loop of data segments but is not part of the
loop.
SE Transaction Set Trailer, ends a transaction set.
GE Functional Group Trailer, ends a group of related transaction sets.
More than one ST/SE pair, each representing a transaction set, may be used within one
functional group. Also more than one LS/LE pair, each representing a bounded loop,
may be used within one transaction set.

B.1.1.3.12 Transaction Set

The transaction set is the smallest meaningful set of information exchanged between
trading partners. The transaction set consists of a transaction set header segment, one
or more data segments in a specified order, and a transaction set trailer segment. See
Figure B.1 - Transmission Control Schematic.

B.1.1.3.12.1 Transaction Set Header and Trailer

A transaction set identifier uniquely identifies a transaction set. This identifier is the first
data element of the Transaction Set Header Segment (ST). A user assigned transaction
set control number in the header must match the control number in the Trailer Segment
(SE) for any given transaction set. The value for the number of included segments in
the SE segment is the total number of segments in the transaction set, including the ST
and SE segments.

B.1.1.3.12.2 Data Segment Groups

The data segments in a transaction set may be repeated as individual data segments
or as unbounded or bounded loops.

B.1.1.3.12.3 Repeated Occurrences of Single Data Segments

When a single data segment is allowed to be repeated, it may have a specified maximum
number of occurrences defined at each specified position within a given transaction set
standard. Alternatively, a segment may be allowed to repeat an unlimited number of
times. The notation for an unlimited number of repetitions is ">1."

B.1.1.3.12.4 Loops of Data Segments

Loops are groups of semantically related segments. Data segment loops may be
unbounded or bounded.

Unbounded Loops
To establish the iteration of a loop, the first data segment in the loop must appear once
and only once in each iteration. Loops may have a specified maximum number of

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repetitions. Alternatively, the loop may be specified as having an unlimited number of

iterations. The notation for an unlimited number of repetitions is ">1."

A specified sequence of segments is in the loop. Loops themselves are optional or

mandatory. The requirement designator of the beginning segment of a loop indicates
whether at least one occurrence of the loop is required. Each appearance of the beginning
segment defines an occurrence of the loop.

The requirement designator of any segment within the loop after the beginning segment
applies to that segment for each occurrence of the loop. If there is a mandatory
requirement designator for any data segment within the loop after the beginning segment,
that data segment is mandatory for each occurrence of the loop. If the loop is optional,
the mandatory segment only occurs if the loop occurs.

Bounded Loops
The characteristics of unbounded loops described previously also apply to bounded
loops. In addition, bounded loops require a Loop Start Segment (LS) to appear before
the first occurrence and a Loop End Segment (LE) to appear after the last consecutive
occurrence of the loop. If the loop does not occur, the LS and LE segments are
suppressed.

B.1.1.3.12.5 Data Segments in a Transaction Set

When data segments are combined to form a transaction set, three characteristics are
applied to each data segment: a requirement designator, a position in the transaction
set, and a maximum occurrence.

B.1.1.3.12.6 Data Segment Requirement Designators

A data segment, or loop, has one of the following requirement designators for health
care and insurance transaction sets, indicating its appearance in the data stream of a
transmission. These requirement designators are represented by a single character
code.

Table B.8 - Data Segment Requirement Designators

DESIGNATOR DESCRIPTION

M- Mandatory This data segment must be included in the transaction set. (Note
that a data segment may be mandatory in a loop of data segments,
but the loop itself is optional if the beginning segment of the loop is
designated as optional.)

O- Optional The presence of this data segment is the option of the sending party.

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B.1.1.3.12.7 Data Segment Position

The ordinal positions of the segments in a transaction set are explicitly specified for that
transaction. Subject to the flexibility provided by the optional requirement designators
of the segments, this positioning must be maintained.

B.1.1.3.12.8 Data Segment Occurrence

A data segment may have a maximum occurrence of one, a finite number greater than
one, or an unlimited number indicated by ">1."

B.1.1.3.13 Functional Group

A functional group is a group of similar transaction sets that is bounded by a functional
group header segment and a functional group trailer segment. The functional identifier
defines the group of transactions that may be included within the functional group. The
value for the functional group control number in the header and trailer control segments
must be identical for any given group. The value for the number of included transaction
sets is the total number of transaction sets in the group. See Figure B.1 - Transmission
Control Schematic.

B.1.1.4 Envelopes and Control Structures

B.1.1.4.1 Interchange Control Structures
Typically, the term "interchange" connotes the ISA/IEA envelope that is transmitted
between trading/business partners. Interchange control is achieved through several
"control" components. The interchange control number is contained in data element
ISA13 of the ISA segment. The identical control number must also occur in data element
02 of the IEA segment. Most commercial translation software products will verify that
these two elements are identical. In most translation software products, if these elements
are different the interchange will be "suspended" in error.

There are many other features of the ISA segment that are used for control measures.
For instance, the ISA segment contains data elements such as authorization information,
security information, sender identification, and receiver identification that can be used
for control purposes. These data elements are agreed upon by the trading partners prior
to transmission.The interchange date and time data elements as well as the interchange
control number within the ISA segment are used for debugging purposes when there is
a problem with the transmission or the interchange.

Data Element ISA12, Interchange Control Version Number, indicates the version of the
ISA/IEA envelope. GS08 indicates the version of the transaction sets contained within
the ISA/IEA envelope. The versions are not required to be the same. An Interchange

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Acknowledgment can be requested through data element ISA14. The interchange

acknowledgment is the TA1 segment. Data element ISA15, Test Indicator, is used
between trading partners to indicate that the transmission is in a "test" or "production"
mode. Data element ISA16, Subelement Separator, is used by the translator for
interpretation of composite data elements.

The ending component of the interchange or ISA/IEA envelope is the IEA segment. Data
element IEA01 indicates the number of functional groups that are included within the
interchange. In most commercial translation software products, an aggregate count of
functional groups is kept while interpreting the interchange. This count is then verified
with data element IEA01. If there is a discrepancy, in most commercial products, the
interchange is suspended. The other data element in the IEA segment is IEA02 which
is referenced above.

See Appendix C, EDI Control Directory, for a complete detailing of the inter-change
control header and trailer. The authors recommend that when two transactions with
different X12 versions numbers are sent in one interchange control structure (multiple
functional groups within one ISA/IEA envelope), the Interchange Control version used
should be that of the most recent transaction version included in the envelope. For the
transmission of HIPAA transactions with mixed versions, this would be a compliant
enveloping structure.

B.1.1.4.2 Functional Groups

Control structures within the functional group envelope include the functional identifier
code in GS01. The Functional Identifier Code is used by the commercial translation
software during interpretation of the interchange to determine the different transaction
sets that may be included within the functional group. If an inappropriate transaction set
is contained within the functional group, most commercial translation software will suspend
the functional group within the interchange. The Application Sender's Code in GS02 can
be used to identify the sending unit of the transmission. The Application Receiver's Code
in GS03 can be used to identify the receiving unit of the transmission. The functional
group contains a creation date (GS04) and creation time (GS05) for the functional group.
The Group Control Number is contained in GS06. These data elements (GS04, GS05,
and GS06) can be used for debugging purposes. GS08,Version/Release/Industry Identifier
Code is the version/release/sub-release of the transaction sets being transmitted in this
functional group.

The Functional Group Control Number in GS06 must be identical to data element 02 of
the GE segment. Data element GE01 indicates the number of transaction sets within
the functional group. In most commercial translation software products, an aggregate

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count of the transaction sets is kept while interpreting the functional group. This count
is then verified with data element GE01.

See Appendix C, EDI Control Directory, for a complete detailing of the functional group
header and trailer.

B.1.1.4.3 HL Structures
The HL segment is used in several X12 transaction sets to identify levels of detail
information using a hierarchical structure, such as relating dependents to a subscriber.
Hierarchical levels may differ from guide to guide.

For example, each provider can bill for one or more subscribers, each subscriber can
have one or more dependents and the subscriber and the dependents can make one
or more claims.

Each guide states what levels are available, the level's usage, number of repeats, and
whether that level has subordinate levels within a transaction set.

For implementations compliant with this guide, the repeats of the loops identified by the
HL structure shall appear in the hierarchical order specified in BHT01, when those
particular hierarchical levels exist. That is, an HL parent loop must be followed by the
subordinate child loops, if any, prior to commencing a new HL parent loop at the same
hierarchical level.

The following diagram, from transaction set 837, illustrates a typical hierarchy.

The two examples below illustrate this requirement:

Example 1 based on Implementation Guide 811X201:

INSURER
First STATE in transaction (child of INSURER)
First POLICY in transaction (child of first STATE)
First VEHICLE in transaction (child of first POLICY)
Second POLICY in transaction (child of first STATE)
Second VEHICLE in transaction (child of second POLICY)
Third VEHICLE in transaction (child of second POLICY)

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Second STATE in transaction (child of INSURER)

Third POLICY in transaction (child of second STATE)
Fourth VEHICLE in transaction (child of third POLICY)

Example 2 based on Implementation Guide 837X141

First PROVIDER in transaction
First SUBSCRIBER in transaction (child of first PROVIDER)
Second PROVIDER in transaction
Second SUBSCRIBER in transaction (child of second PROVIDER)
First DEPENDENT in transaction (child of second SUBSCRIBER)
Second DEPENDENT in transaction (child of second SUBSCRIBER)
Third SUBSCRIBER in transaction (child of second PROVIDER)
Third PROVIDER in transaction
Fourth SUBSCRIBER in transaction (child of third PROVIDER)
Fifth SUBSCRIBER in transaction (child of third PROVIDER)
Third DEPENDENT in transaction (child of fifth SUBSCRIBER)

B.1.1.5 Acknowledgments
B.1.1.5.1 Interchange Acknowledgment, TA1
The TA1 segment provides the capability for the interchange receiver to notify the sender
that a valid envelope was received or that problems were encountered with the
interchange control structure. The TA1 verifies the envelopes only. Transaction
set-specific verification is accomplished through use of the Functional Acknowledgment
Transaction Set, 997. See Section B.1.1.5.2 - Functional Acknowledgment, 997, for
more details. The TA1 is unique in that it is a single segment transmitted without the
GS/GE envelope structure. A TA1 can be included in an interchange with other functional
groups and transactions.

Encompassed in the TA1 are the interchange control number, interchange date and
time, interchange acknowledgment code, and the interchange note code.The interchange
control number, interchange date and time are identical to those that were present in
the transmitted interchange from the trading partner. This provides the capability to
associate the TA1 with the transmitted interchange.TA104, Interchange Acknowledgment
Code, indicates the status of the interchange control structure. This data element
stipulates whether the transmitted interchange was accepted with no errors, accepted
with errors, or rejected because of errors. TA105, Interchange Note Code, is a numerical
code that indicates the error found while processing the interchange control structure.
Values for this data element indicate whether the error occurred at the interchange or
functional group envelope.

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B.1.1.5.2 Functional Acknowledgment, 997

The Functional Acknowledgment Transaction Set, 997, has been designed to allow
trading partners to establish a comprehensive control function as a part of their business
exchange process. This acknowledgment process facilitates control of EDI. There is a
one-to-one correspondence between a 997 and a functional group. Segments within the
997 can identify the acceptance or rejection of the functional group, transaction sets or
segments. Data elements in error can also be identified. There are many EDI
implementations that have incorporated the acknowledgment process in all of their
electronic communications. The 997 is used as a functional acknowledgment to a
previously transmitted functional group.

The 997 is a transaction set and thus is encapsulated within the interchange control
structure (envelopes) for transmission.

B.2 Object Descriptors

Object Descriptors (OD) provide a method to uniquely identify specific locations within
an implementation guide. There is an OD assigned at every level of the X12N
implementation:

1. Transaction Set
2. Loop
3. Segment
4. Composite Data Element
5. Component Data Element
6. Simple Data Element

ODs at the first four levels are coded using X12 identifiers separated by underbars:

Entity Example

1. Transaction Set Identifier plus a unique 837Q1

2 character value

2. Above plus under bar plus Loop 837Q1_2330C

Identifier as assigned within an
implementation guide

3. Above plus under bar plus Segment 837Q1_2330C_NM1

Identifier

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Entity Example

4. Above plus Reference Designator plus 837Q1_2400_SV101_C003

under bar plus Composite Identifier

The fifth and sixth levels add a name derived from the "Industry Term" defined in the
X12N Data Dictionary. The name is derived by removing the spaces.

Entity Example

5. Number 4 above plus 837Q1_2400_SV101_C00302_ProcedureCode

composite sequence plus
under bar plus name

6. Number 3 above plus 837Q1_2330C_NM109__OtherPayerPatientPrimaryIdentifier

Reference Designator plus
two under bars plus name

Said in another way, ODs contain a coded component specifying a location in an

implementation guide, a separator, and a name portion. For example:

Since ODs are unique across all X12N implementation guides, they can be used for a
variety of purposes. For example, as a cross reference to older data transmission
systems, like the National Standard Format for health care claims, or to form XML tags
for newer data transmission systems.

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C EDI Control Directory

C.1 Control Segments
• ISA
Interchange Control Header Segment
• GS
Functional Group Header Segment
• GE
Functional Group Trailer Segment
• IEA
Interchange Control Trailer Segment

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HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE TECHNICAL REPORT • TYPE 3

C.2 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE
TECHNICAL REPORT • TYPE 3 CONTROL SEGMENTS
INTERCHANGE CONTROL HEADER 005010X000
INTERCHANGE• 002 • ISA
CONTROL HEADER
ISA

MAY 4, 2004DETAIL
SEGMENT

ISA - INTERCHANGE CONTROL HEADER

X12 Segment Name: Interchange Control Header
X12 Purpose: To start and identify an interchange of zero or more functional groups and
interchange-related control segments
Segment Repeat: 1

Usage: REQUIRED

2 TR3 Notes: 1. All positions within each of the data elements must be filled.

3 2. For compliant implementations under this implementation guide,

ISA13, the interchange Control Number, must be a positive unsigned
number. Therefore, the ISA segment can be considered a fixed record
length segment.

4 3. The first element separator defines the element separator to be used

through the entire interchange.

5 4. The ISA segment terminator defines the segment terminator used

throughout the entire interchange.

6 5. Spaces in the example interchanges are represented by “.” for clarity.

000
100
1 TR3 Example: ISA✽00✽..........✽01✽SECRET....✽ZZ✽SUBMITTERS.ID..✽ZZ✽
RECEIVERS.ID...✽030101✽1253✽^✽00501✽000000905✽1✽T✽:~

DIAGRAM

ISA01 I01 ISA02 I02 ISA03 I03 ISA04 I04 ISA05 I05 ISA06 I06
Author Info Author Security Security Interchange Interchange
ISA ✽ Qualifier
✽
Information
✽
Info Qual
✽
Information
✽
ID Qual
✽
Sender ID
M1 ID 2/2 M1 AN 10/10 M1 ID 2/2 M1 AN 10/10 M1 ID 2/2 M1 AN 15/15

ISA07 I05 ISA08 I07 ISA09 I08 ISA10 I09 ISA11 I65 ISA12 I11

✽ Interchange ✽ Interchange ✽ Interchange ✽ Interchange ✽ Repetition

✽ Inter Ctrl
ID Qual Receiver ID Date Time Separator Version Num
M1 ID 2/2 M1 AN 15/15 M1 DT 6/6 M1 TM 4/4 M1 1/1 M1 ID 5/5

ISA13 I12 ISA14 I13 ISA15 I14 ISA16 I15

Inter Ctrl Ack Usage
✽ ✽ ✽ ✽ Component ~
Number Requested Indicator Elem Sepera
M1 N0 9/9 M1 ID 1/1 M1 ID 1/1 M1 1/1

APRIL 2008 C.3

 ASC X12N • INSURANCE SUBCOMMITTEE
CONTROL SEGMENTS TECHNICAL REPORT • TYPE 3

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED ISA01 I01 Authorization Information Qualifier M1 ID 2/2

Code identifying the type of information in the Authorization Information
CODE DEFINITION

00 No Authorization Information Present (No

Meaningful Information in I02)
03 Additional Data Identification
REQUIRED ISA02 I02 Authorization Information M 1 AN 10/10
Information used for additional identification or authorization of the interchange
sender or the data in the interchange; the type of information is set by the
Authorization Information Qualifier (I01)
REQUIRED ISA03 I03 Security Information Qualifier M1 ID 2/2
Code identifying the type of information in the Security Information
CODE DEFINITION

00 No Security Information Present (No Meaningful

Information in I04)
01 Password
REQUIRED ISA04 I04 Security Information M 1 AN 10/10
This is used for identifying the security information about the interchange sender
or the data in the interchange; the type of information is set by the Security
Information Qualifier (I03)
REQUIRED ISA05 I05 Interchange ID Qualifier M1 ID 2/2
Code indicating the system/method of code structure used to designate the
sender or receiver ID element being qualified

1000002 This ID qualifies the Sender in ISA06.

CODE DEFINITION

01 Duns (Dun & Bradstreet)

14 Duns Plus Suffix
20 Health Industry Number (HIN)
CODE SOURCE 121: Health Industry Number
27 Carrier Identification Number as assigned by Health
Care Financing Administration (HCFA)
28 Fiscal Intermediary Identification Number as
assigned by Health Care Financing Administration
(HCFA)
29 Medicare Provider and Supplier Identification
Number as assigned by Health Care Financing
Administration (HCFA)
30 U.S. Federal Tax Identification Number
33 National Association of Insurance Commissioners
Company Code (NAIC)
ZZ Mutually Defined
REQUIRED ISA06 I06 Interchange Sender ID M 1 AN 15/15
Identification code published by the sender for other parties to use as the receiver
ID to route data to them; the sender always codes this value in the sender ID
element

C.4 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE
TECHNICAL REPORT • TYPE 3 CONTROL SEGMENTS

REQUIRED ISA07 I05 Interchange ID Qualifier M1 ID 2/2

Code indicating the system/method of code structure used to designate the
sender or receiver ID element being qualified

1000003 This ID qualifies the Receiver in ISA08.

CODE DEFINITION

01 Duns (Dun & Bradstreet)

14 Duns Plus Suffix
20 Health Industry Number (HIN)
CODE SOURCE 121: Health Industry Number
27 Carrier Identification Number as assigned by Health
Care Financing Administration (HCFA)
28 Fiscal Intermediary Identification Number as
assigned by Health Care Financing Administration
(HCFA)
29 Medicare Provider and Supplier Identification
Number as assigned by Health Care Financing
Administration (HCFA)
30 U.S. Federal Tax Identification Number
33 National Association of Insurance Commissioners
Company Code (NAIC)
ZZ Mutually Defined
REQUIRED ISA08 I07 Interchange Receiver ID M 1 AN 15/15
Identification code published by the receiver of the data; When sending, it is used
by the sender as their sending ID, thus other parties sending to them will use this
as a receiving ID to route data to them
REQUIRED ISA09 I08 Interchange Date M 1 DT 6/6
Date of the interchange

1000006 The date format is YYMMDD.

REQUIRED ISA10 I09 Interchange Time M 1 TM 4/4

Time of the interchange

1000007 The time format is HHMM.

REQUIRED ISA11 I65 Repetition Separator M1 1/1
Type is not applicable; the repetition separator is a delimiter and not a data
element; this field provides the delimiter used to separate repeated occurrences
of a simple data element or a composite data structure; this value must be
different than the data element separator, component element separator, and the
segment terminator
REQUIRED ISA12 I11 Interchange Control Version Number M1 ID 5/5
Code specifying the version number of the interchange control segments
CODE DEFINITION

00501 Standards Approved for Publication by ASC X12

Procedures Review Board through October 2003
REQUIRED ISA13 I12 Interchange Control Number M1 N0 9/9
A control number assigned by the interchange sender

1000004 The Interchange Control Number, ISA13, must be identical to the

associated Interchange Trailer IEA02.

7 Must be a positive unsigned number and must be identical to the

value in IEA02.

APRIL 2008 C.5

 ASC X12N • INSURANCE SUBCOMMITTEE
CONTROL SEGMENTS TECHNICAL REPORT • TYPE 3

REQUIRED ISA14 I13 Acknowledgment Requested M1 ID 1/1

Code indicating sender’s request for an interchange acknowledgment

1000038 See Section B.1.1.5.1 for interchange acknowledgment information.

CODE DEFINITION

0 No Interchange Acknowledgment Requested

1 Interchange Acknowledgment Requested (TA1)
REQUIRED ISA15 I14 Interchange Usage Indicator M1 ID 1/1
Code indicating whether data enclosed by this interchange envelope is test,
production or information
CODE DEFINITION

P Production Data
T Test Data
REQUIRED ISA16 I15 Component Element Separator M1 1/1
Type is not applicable; the component element separator is a delimiter and not a
data element; this field provides the delimiter used to separate component data
elements within a composite data structure; this value must be different than the
data element separator and the segment terminator

C.6 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE
TECHNICAL REPORT • TYPE 3 CONTROL SEGMENTS
FUNCTIONAL GROUP HEADER FUNCTIONAL• GROUP
005010X000 002 • GSHEADER
GS

SEGMENT DETAIL

GS - FUNCTIONAL GROUP HEADER

X12 Segment Name: Functional Group Header
X12 Purpose: To indicate the beginning of a functional group and to provide control information
X12 Comments: 1. A functional group of related transaction sets, within the scope of X12
standards, consists of a collection of similar transaction sets enclosed by a
functional group header and a functional group trailer.
Segment Repeat: 1

Usage: REQUIRED

005
100
4 TR3 Example: GS✽XX✽SENDER CODE✽RECEIVER
CODE✽19991231✽0802✽1✽X✽005010X279~

DIAGRAM

GS01 479 GS02 142 GS03 124 GS04 373 GS05 337 GS06 28
Functional
✽ Application ✽ Application ✽ Date Time Group Ctrl
GS ✽
ID Code Send’s Code Rec’s Code
✽ ✽
Number
M1 ID 2/2 M1 AN 2/15 M1 AN 2/15 M1 DT 8/8 M1 TM 4/8 M1 N0 1/9

GS07 455 GS08 480

✽ Responsible ✽ Ver/Release
~
Agency Code ID Code
M1 ID 1/2 M1 AN 1/12

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED GS01 479 Functional Identifier Code M1 ID 2/2

Code identifying a group of application related transaction sets

8 This is the 2-character Functional Identifier Code assigned to each

transaction set by X12. The specific code for a transaction set
defined by this implementation guide is presented in section 1.2,
Version Information.
REQUIRED GS02 142 Application Sender’s Code M 1 AN 2/15
Code identifying party sending transmission; codes agreed to by trading partners

1000009 Use this code to identify the unit sending the information.

REQUIRED GS03 124 Application Receiver’s Code M 1 AN 2/15

Code identifying party receiving transmission; codes agreed to by trading partners

1000010 Use this code to identify the unit receiving the information.

REQUIRED GS04 373 Date M 1 DT 8/8

Date expressed as CCYYMMDD where CC represents the first two digits of the
calendar year
SEMANTIC: GS04 is the group date.

1000011 Use this date for the functional group creation date.

APRIL 2008 C.7

 ASC X12N • INSURANCE SUBCOMMITTEE
CONTROL SEGMENTS TECHNICAL REPORT • TYPE 3

REQUIRED GS05 337 Time M 1 TM 4/8

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S =
integer seconds (00-59) and DD = decimal seconds; decimal seconds are
expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC: GS05 is the group time.

1000012 Use this time for the creation time. The recommended format is
HHMM.

REQUIRED GS06 28 Group Control Number M1 N0 1/9

Assigned number originated and maintained by the sender
SEMANTIC: The data interchange control number GS06 in this header must be
identical to the same data element in the associated functional group trailer,
GE02.

1000119 For implementations compliant with this guide, GS06 must be

unique within a single transmission (that is, within a single ISA to
IEA enveloping structure). The authors recommend that GS06 be
unique within all transmissions over a period of time to be
determined by the sender.
REQUIRED GS07 455 Responsible Agency Code M1 ID 1/2
Code identifying the issuer of the standard; this code is used in conjunction with
Data Element 480
CODE DEFINITION

X Accredited Standards Committee X12

REQUIRED GS08 480 Version / Release / Industry Identifier Code M 1 AN 1/12
Code indicating the version, release, subrelease, and industry identifier of the EDI
standard being used, including the GS and GE segments; if code in DE455 in GS
segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6
are the release and subrelease, level of the version; and positions 7-12 are the
industry or trade association identifiers (optionally assigned by user); if code in
DE455 in GS segment is T, then other formats are allowed
CODE SOURCE 881: Version / Release / Industry Identifier Code

9 This is the unique Version/Release/Industry Identifier Code

assigned to an implementation by X12N. The specific code for a
transaction set defined by this implementation guide is presented
in section 1.2, Version Information.
CODE DEFINITION

005010X279 Standards Approved for Publication by ASC X12

Procedures Review Board through October 2003

C.8 APRIL 2008

 ASC X12N • INSURANCE SUBCOMMITTEE
TECHNICAL REPORT • TYPE 3 CONTROL SEGMENTS
FUNCTIONAL GROUP TRAILER FUNCTIONAL• GROUP
005010X000 002 • GETRAILER
GE

SEGMENT DETAIL

GE - FUNCTIONAL GROUP TRAILER

X12 Segment Name: Functional Group Trailer
X12 Purpose: To indicate the end of a functional group and to provide control information
X12 Comments: 1. The use of identical data interchange control numbers in the associated
functional group header and trailer is designed to maximize functional
group integrity. The control number is the same as that used in the
corresponding header.
Segment Repeat: 1

Usage: REQUIRED

001
100
3 TR3 Example: GE✽1✽1~

DIAGRAM

GE01 97 GE02 28
Number of Group Ctrl
GE ✽
TS Included
✽
Number ~
M1 N0 1/6 M1 N0 1/9

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED GE01 97 Number of Transaction Sets Included M1 N0 1/6

Total number of transaction sets included in the functional group or interchange
(transmission) group terminated by the trailer containing this data element
REQUIRED GE02 28 Group Control Number M1 N0 1/9
Assigned number originated and maintained by the sender
SEMANTIC: The data interchange control number GE02 in this trailer must be
identical to the same data element in the associated functional group header,
GS06.

APRIL 2008 C.9

 ASC X12N • INSURANCE SUBCOMMITTEE
CONTROL SEGMENTS TECHNICAL REPORT • TYPE 3
INTERCHANGE CONTROL TRAILER 005010X000
INTERCHANGE• 002 • IEA
CONTROL TRAILER
IEA

SEGMENT DETAIL

IEA - INTERCHANGE CONTROL TRAILER

X12 Segment Name: Interchange Control Trailer
X12 Purpose: To define the end of an interchange of zero or more functional groups and
interchange-related control segments
Segment Repeat: 1

Usage: REQUIRED

000
100
5 TR3 Example: IEA✽1✽000000905~

DIAGRAM

IEA01 I16 IEA02 I12

✽ Num of Incl ✽ Inter Ctrl

IEA Funct Group Number ~
M1 N0 1/5 M1 N0 9/9

ELEMENT DETAIL

REF. DATA
USAGE DES. ELEMENT NAME ATTRIBUTES

REQUIRED IEA01 I16 Number of Included Functional Groups M1 N0 1/5

A count of the number of functional groups included in an interchange
REQUIRED IEA02 I12 Interchange Control Number M1 N0 9/9
A control number assigned by the interchange sender

C.10 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270/271
TECHNICAL REPORT • TYPE 3 HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

D Change Summary
This is the ASC X12N implementation guide for the 270/271 Health Care Eligibil-
ity Benefit Inquiry and Response. The following substantive changes have oc-
curred since the previous Implementation Guide 004050X138, the 270/271
Health Care Eligibility Benefit Inquiry and Response.

D.1 Entire Document

1. All previous references to HCFA have been changed to CMS
2. Many segments and elements have TR3 segment notes, or notes added in
addition to situational notes added to each segment/element that’s usage is
“situational”

D.2 Changes to Section 1

3. Sections have been added, re-ordered and combined. New section 1 en-
compasses old sections 1 and 2. New section 2 encompassed old section
3. Section cross references updated to reflect new section and subsection
numbers and names
4. Section 1.4.1 - Additional notes added to clarify definitions of Subscriber
and Dependent as it relates to Coordination of Benefits.
5. Section 1.4.2 - Updated definition of “Subscriber” and “Dependent” to sync
up with 837 Implementation Guide
6. Section 1.4.2 - Updated/Clarified Payer expectations on 271. Payer must re-
turn subscriber/dependent information in 271 as it is needed in subsequent
transactions.
7. Section 1.4.7 - New requirements regarding what MUST be returned on
EVERY 271, such as plan begin date (346) or plan range of dates (291). If
benefit dates for a specific EB03 value differ from plan begin or plan range,
a value of 348 or 292 must be returned in the 2110 C/D. Also required is the
service type code with associated EB01value (1-8), other payers/plans if
known, Primary Care Provider if applicable.
8. Section 1.4.7 - Added note #6 which further clarifies what information sent
on the 270 should be returned on the 271.
9. Section 1.4.7 - New requirements/clarification regarding service type codes
that must be returned on 271.
10. Section 1.4.7 - Guidance regarding how specific service type codes fit into
the more generic categories.
11. Section 1.4.7 - New paragraphs added to provide guidance on Person Spe-
cific benefits.
12. Section 1.4.8 - New Required Alternate and Optional Name/Date of Birth,
Member ID/Date of Birth Search Options added.
13. Section 1.4.12 - Message Segments section added.

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HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE TECHNICAL REPORT • TYPE 3

14. Section 1.6.1 - 997 is no longer required as a response to a batch or real

time transaction.
15. Section 1.6.2 - 999 Implementation Acknowledgement outlines the require-
ments as a response to batch or real time transactions.

D.3 Changes to Section 2

16. Section 3 is now Section 2
270 and 271 Loops and Segments
17. All segments have an X12 Segment Name, X12 Segment Purpose and X12
Syntax area in the “implementation” (now known as “segment detail”) sec-
tion. As well, the notes and examples as now referred to as “TR3 Notes”
and “TR3 Example”.
270 and 271 Elements
18. All elements have an “implementation name” formerly referred to as the “in-
dustry” name.
270 Changes
19. ST03 - Usage changed from Not Used to Required
20. BHT/BHT02 - Removed code value 36
21. BHT/BHT06 - Removed code value RU - Medical Service Reservation
22. 2100A/NM1/NM103 - Usage changed from Situational to Required
23. 2100B/NM1/NM103 - Usage changed from Situational to Required
24. 2100B/N4/N407 -Usage changed from Not Used to Situational
25. 2100B/PRV/PRV02 - Usage changed from Required to Situational. Code
Value ZZ removed and replaced with Code Value PXC (Provider Health
Care Taxonomy Code)
26. 2100B/PRV/PRV03 - Usage changed from Required to Situational
27. 2100B/PER - Segment Removed
28. 2100C/NM1/NM108 - Code Value ZZ removed and replaced with Code
Value II (Standard Unique Health Identifier for each Individual in the United
States)
29. 2100C/REF/REF01 - Code Value 49 (Family Unit Number) removed
30. 2100C/REF/REF01 - Code value Y4 added with usage note
31. 2100C/N4/N401 - Usage changed from Situational to required
32. 2100C/PRV/PRV02 - Code Value ZZ removed and replaced with Code
Value PXC (Provider Health Care Taxonomy Code)
33. 2100C/DTP/DTP01 - Added code 291 (Plan) standardizing all requests to
one code. Removed code values 307, 435 and 472.
34. 2110C/EQ/EQ02-8 - Product/Service ID added - Usage “Not Used”
35. 2110C/EQ/EQ03 - Code values IND, DEP, ECH, ESP, EMP, SPC and SPO
removed

D.2 APRIL 2008

ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270/271
TECHNICAL REPORT • TYPE 3 HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

36. 2110C/EQ/EQ04 - Usage changed from Situational to Not Used

37. 2110C/III - Diagnosis code functionality moved to 2100C HI segment.
Codes 01, 03, 04, 05, 06, 07, 08, 13, 14, 15, 20, 49 and 57 added to III02
38. 2100D/REF/REF01 - Code value Y4 added with usage note
39. 2100D/N4/N401 - Usage changed from Situational to required
40. 2100D/PRV/PRV02 - Code Value ZZ removed and replaced with Code
Value PXC (Provider Health Care Taxonomy Code)
41. 2100D/DTP/DTP01 - Removed code value 307; added code value 291
42. 2110D/EQ/EQ02-8 - Product/Service ID added - Usage “Not Used”
43. 2110D/EQ/EQ03 - Usage changed from Situational to Not Used
44. 2110D/EQ/EQ04 - Usage changed from Situational to Not Used
45. 2110D/III - Diagnosis code functionality moved to 2100D HI segment.
Codes 01, 03, 04, 05, 06, 07, 08, 13, 14, 15, 20, 49 and 57 added to III02
271
46. ST03 - Usage changed from Not Used to Required
47. 2100A/NM1/NM108 - XV note removed, XX note removed
48. 2100A/REF - Delete 2100A REF segment in it’s entirety
49. 2100A/PER03, PER05 and PER07 - Add code UR-Uniform Resource Loca-
tor (URL)
50. 2100A/AAA/AAA03 - Updated note on code value 04
51. 2100B/NM1/NM108 - XV note removed, XX note removed
52. 2100B/PRV/PRV02 - Usage changed from Required to Situational. Errone-
ous note referring to National Provider ID removed. Code Value ZZ re-
moved and replaced with Code Value PXC (Provider Health Care Taxon-
omy Code).
53. 2100B/PRV/PRV03 - Usage changed from Required to Situational
54. 2100C/NM1/NM106 - Changed usage from Situational to Not Used
55. 2100C/NM1/NM108 - Code Value ZZ removed and replaced with Code
Value II (Standard Unique Health Identifier for each Individual in the United
States)
56. 2100C/REF/REF01 - Updated Note on Code Value 49 to reference PBM’s.
57. 2100C/REF/REF01 - Add Code Value -Y4 Agency Claim Number
58. 2100C/N4 - Added Segment Notes
59. 2100C/N4/N405 - Change usage from Situational to Not Used
60. 2100C/N4/N406 - Change usage from Situational to Not Used
61. 2100C/N4/N407 - Change usage from Not Used to Situational
62. 2100C/PER - Delete PER segment in it’s entirety
63. 2100C/AAA/AAA03 - Add note to Code Value 58-Invalid/Missing Date-of-
Birth, 71-Patient Date of Birth does not match that for the Patient on the Da-

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HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE TECHNICAL REPORT • TYPE 3

tabase, 72-Invalid/Missing Subscriber/Insured ID, 73-Invalid/Missing Sub-

scriber/Insured Name, 75-Subscriber/Insured Not Found
64. 2100C/AAA/AAA03 - Remove code values 64-Invalid/Missing Patient ID, 65-
Invalid/Missing Patient Name, 66-Invalid/Missing Patient Gender Code, 67-
Patient Not Found, 68-Duplicate Patient ID Number, 77-Subscriber Found,
Patient Not Found
65. 2100C/PRV/PRV02 - Changed usage from Required to Situational. Code
Value ZZ removed and replaced with Code Value PXC (Provider Health
Care Taxonomy Code)
66. 2100C/PRV/PRV03 - Changed usage from Required to Situational
67. 2100C/DMG - Added to Situational Note 1, and added additional Situational
notes.
68. 2100C/DMG/DMG02 - “Added by copying Situational Note 1 from segment
note to element note. Moved current note ”use this date for the date of
birth..." to a note, not a Situational note.
69. 2100C/INS/INS09 - Changed usage from Situational to Not Used
70. 2100C/INS/INS10 - Changed usage from Situational to Not Used
71. 2100C HI - Added HI segment and elements
72. 2100C/DTP - Changed and added TR3 segment notes
73. 2100C/MPI - Added MPI segment and elements
74. 2110C/EB - Updated Situational Rule.
75. 2110C/EB/EB02 - Added clarifying note regarding relationship to EB01 value
76. 2110C/EB/EB03 - Added Code Values: CQ-Case Management, DS-Dia-
betic Supplies, ON-Oncology, PT-Physical Therapy, PU-Pulmonary, RN-Re-
nal, RT-Residential Psychiatric Treatment
77. 2110C/EB/EB03 - Revised note on Code Value 30
78. 2110C/EB/EB04 - Add note to Code Value OT: When this code is returned
by Medicare or a Medicare Part D administrator, this code indicates a type
of insurance of Medicare Part D
79. 2110C/EB/EB07 - Added clarifying note re: Patient portion of responsibility
and usage related to EB01 value
80. 2110C/EB/EB08 - Added clarifying note re: Patient portion of responsibility
and usage related to EB01 value
81. 2110C/EB/EB09 - Added Code Values: 8H-Minimum, M2-Maximum, D3-
Number of Co-insurance Days
82. 2110C/EB/EB12 - Added Code Value: W-Not applicable
83. 2110C/EB/EB13-8 - Added EB13-8 as Situational
84. 2110C/REF/REF01 - Updated Note on Code Value 49 to reference PBM’s.
85. 2110C/REF/REF01 - Added Code Values and Definitions: ALS-Alternative
List ID, CLI-Coverage List ID
86. 2110C/MSG - Added TR3 segment notes

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ASC X12N • INSURANCE SUBCOMMITTEE 005010X279 • 270/271
TECHNICAL REPORT • TYPE 3 HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

87. 2110C/DTP/DTP01 Added Code Values 291 and 346

88. 2115C/III - Removed references to Principle Diagnosis and Diagnosis
Codes in the TR3 segment notes
89. 2115C/III/III01 - Removed code values BF and BK, added code values GR
and NI
90. 2115C/III/III02 - Added Code Values: 01-Pharmacy, 03-School, 04-Home-
less Shelter, 05-Indian Health Service Free-standing Facility, 06-Indian
Health Service Provider-based Facility, 07-Tribal 638 Free-standing Facility,
08-Tribal 638 Provider-based Facility, 13-Assisted Living, 14-Group Home,
15-Mobile Unit, 20 Urgent Care Facility, 49-Independent Clinic, 57-Non-
Residential Substance Abuse Treatment Facility
91. 2110C/LS - Added TR3 segment notes
92. 2120C/NM1/NM101 - Added Code Value: 1I-Preferred Provider Organiza-
tion and Situational note for usage.
93. 2120C/NM1/NM108 - XV note removed, XX note removed, Code Value ZZ
removed and replaced with Code Value II (Standard Unique Health Identi-
fier for each Individual in the United States)
94. 2120C/NM1/NM110 - Added Code Values: 27-Domestic Partner, 48-Em-
ployee
95. 2120C/N4/N406 - Added usage note for Department of Defense
96. 2120C/N4/N407 - Change usage from Not Used to Situational
97. 2120C/PER - Added TR3 segment notes
98. 2120C/PER/PER03 - Added Code Value UR-Universal Resource Locator
(URL)
99. 2120C/PER/PER05 - Added Code Value UR-Universal Resource Locator
(URL)
100. 2120C/PER/PER07 - Added Code Value UR-Universal Resource Locator
(URL)
101. 2120C/PRV/PRV02 - Usage changed from Required to Situational, Code
Value ZZ removed and replaced with Code Value PXC (Provider Health
Care Taxonomy Code)
102. 2120C/PRV/PRV03 - Usage changed from Required to Situational
103. 2120C/LE - Added TR3 segment notes
104. 2100D/NM1/NM106 - Changed usage from Situational to Not Used
105. 2100D/NM1/NM108 - Changed usage from Situational to Not Used
106. 2100D/NM1/NM109 - Changed usage from Situational to Not Used
107. 2100D/REF/REF01 - Updated Note on Code Value 49 to reference PBM’s.
Update note too to address Family Unit Number usage
108. 2100D/REF/REF01 - Remove Code Value: 1W-Member Identification Num-
ber
109. 2100D/REF/REF01 - Add Code Value -Y4 Agency Claim Number
110. 2100D/N4 - Added Segment Notes

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111. 2100D/N4/N407 - Change usage from Not Used to Situational

112. 2100D/PER - Delete PER segment in it’s entirety
113. 2100D/AAA/AAA03 - Add usage notes to code values: 58-Invalid/Missing
Date of Birth, 71-Patient Birthdate Does Not Match That for the Patient on
the Database.
114. 2100D/PRV/PRV02 - Changed usage from Required to Situational, Code
Value ZZ removed and replaced with Code Value PXC (Provider Health
Care Taxonomy Code)
115. 2100D/PRV/PRV03 - Changed usage from Required to Situational
116. 2100D/DMG - Added to Situational Note 1, and added additional Situational
notes.
117. 2100D/DMG/DMG02 - Added by copying Situational Note 1 from segment
note to element note. Moved current note “use this date for the date of
birth...” to a note, not a Situational note.
118. 2100D/INS/INS02 - Add Code Values: 20-Employee, 39-Organ Donor, 40-
Cadaver Donor, 53-Life Partner, G8-Other Relationship.
119. 2100D/INS/INS09 - Changed usage from Situational to Not Used
120. 2100D/INS/INS10 - Changed usage from Situational to Not Used
121. 2100D HI - Added HI segment and elements
122. 2100D/DTP - Changed and added TR3 segment notes
123. 2100D/MPI - Added MPI segment and elements
124. 2110D/EB - Updated Situational Rule.
125. 2110D/EB/EB02 - Added clarifying note regarding relationship to EB01 value
126. 2110D/EB/EB03 - Added Code Values: CQ-Case Management, DS-Dia-
betic Supplies, ON-Oncology, PT-Physical Therapy, PU-Pulmonary, RN-Re-
nal, RT-Residential Psychiatric Treatment
127. 2110D/EB/EB03 - Revised note on Code Value 30
128. 2110D/EB/EB04 - Add note to Code Value OT: When this code is returned
by Medicare or a Medicare Part D administrator, this code indicates a type
of insurance of Medicare Part D
129. 2110D/EB/EB07 - Added clarifying note re: Patient portion of responsibility
and usage related to EB01 value
130. 2110D/EB/EB08 - Added clarifying note re: Patient portion of responsibility
and usage related to EB01 value
131. 2110D/EB/EB09 - Added Code Values: 8H-Minimum, M2-Maximum, D3-
Number of Co-insurance Days
132. 2110D/EB/EB12 - Added Code Value: W-Not applicable
133. 2110D/EB/EB13-8 - Added EB13-8 as Situational
134. 2110D/REF/REF01 - Updated Note on Code Value 49 to reference PBM’s.
Update note too to address Family Unit Number usage

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135. 2110D/REF/REF01 - Added Code Values and Definitions: ALS-Alternative

List ID, CLI-Coverage List ID
136. 2110D/DTP - Added TR3 segment notes
137. 2110D/DTP/DTP01 Added Code Values 291 and 346
138. 2110D/MSG - Added TR3 segment notes
139. 2115D/III - Removed references to Principle Diagnosis and Diagnosis
Codes in the TR3 segment notes
140. 2115D/III/III01 - Removed code values BF and BK, added code values GR
and NI
141. 2115D/III/III02 - Added Code Values: 01-Pharmacy, 03-School , 04-Home-
less Shelter, 05-Indian Health Service Free-standing Facility, 06-Indian
Health Service Provider-based Facility, 07-Tribal 638 Free-standing Facility,
08-Tribal 638 Provider-based Facility, 13-Assisted Living, 14-Group Home,
15-Mobile Unit, 20 Urgent Care Facility, 49-Independent Clinic, 57-Non-
Residential Substance Abuse Treatment Facility
142. 2110D/LS - Added TR3 segment notes
143. 2120D/NM1/NM101 - Added Code Value: 1I-Preferred Provider Organiza-
tion and Situational note for usage.
144. 2120D/NM1/NM108 - XV note removed, XX note removed, Code Value ZZ
removed and replaced with Code Value II (Standard Unique Health Identi-
fier for each Individual in the United States)
145. 2120D/NM1/NM110 - Added Code Values: 27-Domestic Partner, 48-Em-
ployee
146. 2120D/N4/N406 - Added usage note for Department of Defense
147. 2120D/N4/N407 - Change usage from Not Used to Situational
148. 2120D/PER - Added TR3 segment notes
149. 2120D/PER/PER03 - Added Code Value UR-Universal Resource Locator
(URL)
150. 2120D/PER/PER05 - Added Code Value UR-Universal Resource Locator
(URL)
151. 2120D/PER/PER07 - Added Code Value UR-Universal Resource Locator
(URL)
152. 2120D/PRV/PRV02 - Usage changed from Required to Situational, Code
Value ZZ removed and replaced with Code Value PXC (Provider Health
Care Taxonomy Code)
153. 2120D/PRV/PRV03 - Usage changed from Required to Situational
154. 2110D/LE - Added TR3 segment notes
Section 3
155. Examples updated to reflect new requirements

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Appendix A
156. Added Code Sources: 896 - International Classification of Diseases, 10th
Revision, Procedure Coding System (ICD-10-PCS), 897 - International Clas-
sification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM);
932 - Universal Postal Codes; DOD1 - Military Rank and Health Care Serv-
ice Region; DOD2 - Paygrade
157. Deleted Code Sources: 43 - FIPS-55 (Named Populated Places); 77 - X12
Directories; 121 - Health Industry Number; 134 - National Drug Code; 411 -
Centers for Medicare and Medicaid Services (CMS) Claim Payment Re-
mark Codes; 507 - Health Care Claim Status Category Code; 508 - Health
Care Claim Status Code; 530 - National Council for Prescription Drug Pro-
grams Reject/Payment Codes

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E Data Element Glossary

E.1 Data Element Name Index
This section contains an alphabetic listing of data elements used in this im-
plementation guide. Consult the X12N Data Element Dictionary for a com-
plete list of all X12N Data Elements. Data element names in normal type are
generic ASC X12 names. Italic type indicates a health care industry defined
name.

Name Payment Date

Definition Date of payment.
Transaction Set ID 277
Locator Key D | 2200D | SPA12 | C001-2 | 373 .............. 156

H=Header, D=Detail, S=Summary

Loop ID
Segment ID/Reference Designator
Composite ID-Sequence
Data Element Number
Page Number

Amount Qualifier Code Benefit Percent

Code to qualify amount. Benefit percentage as qualifed by the eligibility
or benefit information and service type code
270 - Eligibility Benefit Inquiry
D | 2110C | AMT01 | - | 522 ...............136 271 - Eligibility Benefit Response
D | 2110C | AMT01 |
AUTHORIZATION OR CERTIFICATION INDICATOR
- | 522 ...............137 D | 2110C | EB08 | - | 954 .............. 301
D | 2110D |
BENEFIT QUANTITY
EB08 | - | 954 .............. 404

Authorization or Certification
Indicator Benefit Quantity
A yes/no indicator that identifies whether an Benefit quantity as qualified by preceeding
authorization or certification is required per plan qualifier.
provisions. 271 - Eligibility Benefit Response
271 - Eligibility Benefit Response D | 2110C | EB10 | - | 380 .............. 302
D | 2110C | EB11 | - | 1073 .............302 D | 2110C | HSD02 | - | 380 .............. 310
D | 2110D | EB11 | - | 1073 .............406 D | 2110D | EB10 | - | 380 .............. 405
BENEFIT AMOUNT
D | 2110D
BENEFIT RELATED ENTITY ADDRESS LINE
| HSD02 | - | 380 .............. 413

Benefit Amount
Benefit Related Entity Address
Benefit amount as qualifed by the eligibility or
benefit information and service type code Line
Street Address of the entity related to benefits
271 - Eligibility Benefit Response described in the transaction.
D | 2110C | EB07 | - | 782 ...............300
D | 2110D |
BENEFIT COVERAGE LEVEL CODE
EB07 | - | 782 ...............404 271 - Eligibility Benefit Response
D | 2120C | N301 | - | 166 .............. 335
D | 2120C | N302 | - | 166 .............. 335
Benefit Coverage Level Code D | 2120D | N301 | - | 166 .............. 438
D | 2120D | N302 | - | 166 .............. 438
Code indicating which family members are BENEFIT RELATED ENTITY CITY NAME

provided coverge for this insured.

271 - Eligibility Benefit Response Benefit Related Entity City
D | 2110C | EB02 | - | 1207 .............292
D | 2110D | EB02 | - | 1207 .............396
Name
BENEFIT PERCENT
The city name of the entity related to benefits
described in the transaction.
271 - Eligibility Benefit Response
D | 2120C | N401 | - | 19 ................ 336

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D | 2120D |
BENEFIT RELATED ENTITY COMMUNICATION NUMBER
N401 | - | 19 ................ 439 Benefit Related Entity Identifier
Unique identifier for a benefit related entity or
another information source associated with an
Benefit Related Entity individual subscriber or dependent.
Communication Number
271 - Eligibility Benefit Response
Communications number to contact the person, D | 2120C | NM109 | - | 67 ................ 333
group or organization identified as the D | 2120D | NM109 | - | 67 ................ 436
associated benefit related entity contact name.
BENEFIT RELATED ENTITY LAST OR ORGANIZATION NAME

271 - Eligibility Benefit Response

D | 2120C | PER04 | - | 364 .............. 341 Benefit Related Entity Last or
D | 2120C | PER06 | - | 364 .............. 342 Organization Name
D | 2120C | PER08 | - | 364 .............. 343
D | 2120D | PER04 | - | 364 .............. 444 Lat name or organization name of the benefit
D | 2120D | PER06 | - | 364 .............. 445 related entity associated with an individual
D | 2120D | PER08 | - | 364 .............. 446 subscriber or dependent.
BENEFIT RELATED ENTITY CONTACT NAME

271 - Eligibility Benefit Response

D | 2120C | NM103 | - | 1035 ............ 331
Benefit Related Entity Contact D | 2120D | NM103 |
BENEFIT RELATED ENTITY LOCATION QUALIFIER
- | 1035 ............ 434
Name
The name at the benefit related entity to whom
inquiries about the transaction may be directed. Benefit Related Entity Location
Qualifier
271 - Eligibility Benefit Response
D | 2120C | PER02 | - | 93 ................ 340 The code to qualify the location of the entity
D | 2120D | PER02 | - | 93 ................ 443 related to benefits described in the transaction.
BENEFIT RELATED ENTITY COUNTRY CODE

271 - Eligibility Benefit Response

D | 2120C | N405 | - | 309 .............. 338
Benefit Related Entity Country D | 2120D |
BENEFIT RELATED ENTITY MIDDLE NAME
N405 | - | 309 .............. 441
Code
The country code of the entity related to
benefits described in the transaction. Benefit Related Entity Middle
Name
271 - Eligibility Benefit Response
D | 2120C | N404 | - | 26 ................ 337 Middle name of the benefit related entity
D | 2120D | N404 | - | 26 ................ 440 associated with an individual subscriber or
dependent.
BENEFIT RELATED ENTITY COUNTRY SUBDIVISION CODE

271 - Eligibility Benefit Response

Benefit Related Entity Country D | 2120C | NM105 | - | 1037 ............ 331
Subdivision Code D | 2120D | NM105 |
BENEFIT RELATED ENTITY NAME SUFFIX
- | 1037 ............ 434

The country subdivision code of the entity

related to benefits described in the transaction.
Benefit Related Entity Name
271 - Eligibility Benefit Response Suffix
D | 2120C | N407 | - | 1715 ............ 338
D | 2120D | N407 | - | 1715 ............ 441 Suffix for the name of the benefit related entity
associated with an individual subscriber or
BENEFIT RELATED ENTITY DOD HEALTH SERVICE REGION

dependent.
Benefit Related Entity DOD 271 - Eligibility Benefit Response
Health Service Region D | 2120C | NM107 | - | 1039 ............ 332
D | 2120D | NM107 | - | 1039 ............ 435
The Department of Defence (DOD) Health BENEFIT RELATED ENTITY POSTAL ZONE OR ZIP CODE

Service Region of the entity related to benefits

described in the transaction.
Benefit Related Entity Postal
271 - Eligibility Benefit Response Zone or ZIP Code
D | 2120C | N406 | - | 310 .............. 338
D | 2120D | N406 | - | 310 .............. 441 The postal zone or ZIP Code of the entity
associated with benefits described in the
BENEFIT RELATED ENTITY FIRST NAME

transaction.
Benefit Related Entity First 271 - Eligibility Benefit Response
Name D | 2120C | N403 | - | 116............... 337
D | 2120D | N403 | - | 116............... 440
The first name of the person identified as the BENEFIT RELATED ENTITY RELATIONSHIP CODE

benefit related entity, ofr an individual

subscriber or dependent.
271 - Eligibility Benefit Response
D | 2120C | NM104 | - | 1036 ............ 331
D | 2120D | NM104 |
BENEFIT RELATED ENTITY IDENTIFIER
- | 1036 ............ 434

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Benefit Related Entity Contact Function Code

Relationship Code Code identifying the major duty or responsibility
Code indicating Benefit Related Entity’s of the person or group named.
relationship to the patient. 271 - Eligibility Benefit Response
271 - Eligibility Benefit Response D | 2100A | PER01 | - | 366 .............. 222
D | 2120C | NM110 | - | 706 .............. 334 D | 2120C | PER01 | - | 366 .............. 340
D | 2120D | NM110 | - | 706 .............. 437 D | 2120D | PER01 |
COUNTRY CODE
- | 366 .............. 443
BENEFIT RELATED ENTITY STATE CODE

Benefit Related Entity State Country Code

Code Code indicating the geographic location.
The state postal code of the entity related to 270 - Eligibility Benefit Inquiry
benefits described in the transaction. D | 2100B | N404 | - | 26 .................. 83
D | 2100C | N404 | - | 26 ................ 102
271 - Eligibility Benefit Response D | 2100D | N404 | - | 26 ................ 159
COUNTRY SUBDIVISION CODE

D | 2120C | N402 | - | 156 .............. 337

D | 2120D |
BIRTH SEQUENCE NUMBER
N402 | - | 156 .............. 440
Country Subdivision Code
Code identifying the country subdivision.
Birth Sequence Number
A number indicating the order of birth for the 270 - Eligibility Benefit Inquiry
identified person in relationship to family D | 2100B | N407 | - | 1715 .............. 83
members with the same date of birth. D | 2100C | N407 | - | 1715 ............ 102
D | 2100D |
COVERAGE LEVEL CODE
N407 | - | 1715 ............ 159
270 - Eligibility Benefit Inquiry
D | 2100C | INS17 | - | 1470 .............112
D | 2100D | INS17 | - | 1470 ............ 169
Coverage Level Code
271 - Eligibility Benefit Response Code indicating the level of coverage being
D | 2100C | INS17 | - | 1470 ............ 273 provided for this insured
D | 2100D | INS17 | - | 1470 ............ 377
CODE CATEGORY
270 - Eligibility Benefit Inquiry
D | 2110C |
DATE TIME PERIOD
EQ03 | - | 1207 ............ 134
Code Category
Specifies the situation or category to which the Date Time Period
code applies.
Expression of a date, a time, or a range of
271 - Eligibility Benefit Response dates, times, or dates and times.
D | 2115C | III03 | - | 1136............. 327
D | 2115D | III03 | - | 1136............. 430 270 - Eligibility Benefit Inquiry
CODE LIST QUALIFIER CODE
D | 2100C | DTP03 | - | 1251 ............ 123
D | 2110C | DTP03 | - | 1251 ............ 145
D | 2100D | DTP03 | - | 1251 ............ 180
Code List Qualifier Code D | 2110D | DTP03 | - | 1251 ............ 199
Code identifying a specific industry code list.
271 - Eligibility Benefit Response
270 - Eligibility Benefit Inquiry D | 2100C | DTP03 | - | 1251 ............ 284
D | 2110C | III01 | - | 1270 ............ 139 D | 2100C | MPI07 | - | 1251 ............ 288
D | 2110D | III01 | - | 1270 ............ 193 D | 2100D | DTP03 | - | 1251 ............ 388
D | 2100D | MPI07 | - | 1251 ............ 392
271 - Eligibility Benefit Response DATE TIME PERIOD FORMAT QUALIFIER

D | 2115C | III01 | - | 1270 ............ 325

D | 2115D | III01 | - | 1270 ............ 428
COMMUNICATION NUMBER QUALIFIER

Date Time Period Format

Qualifier
Communication Number Code indicating the date format, time format, or
Qualifier date and time format.
Code identifying the type of communication 270 - Eligibility Benefit Inquiry
number. D | 2100C | DMG01 | - | 1250 ............ 108
D | 2100C | DTP02 | - | 1250 ............ 123
271 - Eligibility Benefit Response
D | 2110C | DTP02 | - | 1250 ............ 145
D | 2100A | PER03 | - | 365 .............. 222
D | 2100D | DMG01 | - | 1250 ............ 165
D | 2100A | PER05 | - | 365 .............. 223
D | 2100D | DTP02 | - | 1250 ............ 180
D | 2100A | PER07 | - | 365 .............. 224
D | 2110D | DTP02 | - | 1250 ............ 199
D | 2120C | PER03 | - | 365 .............. 341
D | 2120C | PER05 | - | 365 .............. 342 271 - Eligibility Benefit Response
D | 2120C | PER07 | - | 365 .............. 343 D | 2100C | DMG01 | - | 1250 ............ 269
D | 2120D | PER03 | - | 365 .............. 444 D | 2100C | DTP02 | - | 1250 ............ 284
D | 2120D | PER05 | - | 365 .............. 445 D | 2100C | MPI06 | - | 1250 ............ 288
D | 2120D
CONTACT FUNCTION CODE
| PER07 | - | 365 .............. 446 D | 2110C | DTP02 | - | 1250 ............ 318
D | 2100D | DMG01 | - | 1250 ............ 373
D | 2100D | DTP02 | - | 1250 ............ 388
D | 2100D | MPI06 | - | 1250 ............ 392

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D | 2110D | DTP02 |
DATE TIME QUALIFIER
- | 1250 ............ 421 Dependent Country
Subdivision Code
Date Time Qualifier The country subdivision code of the dependent.
Code specifying the type of date or time or both 271 - Eligibility Benefit Response
date and time. D | 2100D |
DEPENDENT ELIGIBILITY OR BENEFIT IDENTIFIER
N407 | - | 1715 ............ 365

270 - Eligibility Benefit Inquiry

D | 2100C | DTP01 | - | 374 .............. 123
D | 2110C | DTP01 | - | 374 .............. 144 Dependent Eligibility or Benefit
D | 2100D | DTP01 | - | 374 .............. 180 Identifier
D | 2110D | DTP01 | - | 374 .............. 198
Number associated with the dependent for the
271 - Eligibility Benefit Response eligibility or benefit being described.
D | 2100C | DTP01 | - | 374 .............. 283
271 - Eligibility Benefit Response
D | 2110C | DTP01 | - | 374 .............. 317
D | 2110D | REF02 | - | 127 .............. 419
D | 2100D | DTP01 | - | 374 .............. 387 DEPENDENT FIRST NAME

D | 2110D
DELIVERY FREQUENCY CODE
| DTP01 | - | 374 .............. 420

Dependent First Name

Delivery Frequency Code The first name of the dependent.
Codw which specifies frequency by which 270 - Eligibility Benefit Inquiry
services can be performed. D | 2100D | NM104 | - | 1036 ............ 152
271 - Eligibility Benefit Response 271 - Eligibility Benefit Response
D | 2110C | HSD07 | - | 678 .............. 312 D | 2100D | NM104 |
DEPENDENT GENDER CODE
- | 1036 ............ 355
D | 2110D | HSD07 |
DELIVERY PATTERN TIME CODE
- | 678 .............. 415

Dependent Gender Code

Delivery Pattern Time Code A code indicating the gender of the dependent.
Code which specifies the time delivery pattern
270 - Eligibility Benefit Inquiry
of the services.
D | 2100D | DMG03 | - | 1068 ............ 166
271 - Eligibility Benefit Response
271 - Eligibility Benefit Response
D | 2110C | HSD08 | - | 679 .............. 313
D | 2100D | DMG03 | - | 1068 ............ 373
D | 2110D | HSD08 |
DEPENDENT ADDRESS LINE
- | 679 .............. 416 DEPENDENT LAST NAME

Dependent Address Line Dependent Last Name

The last name of the dependent.
The street address of the patient.
270 - Eligibility Benefit Inquiry
270 - Eligibility Benefit Inquiry
D | 2100D | NM103 | - | 1035 ............ 152
D | 2100D | N301 | - | 166 .............. 157
D | 2100D | N302 | - | 166 .............. 157 271 - Eligibility Benefit Response
D | 2100D | NM103 | - | 1035 ............ 355
271 - Eligibility Benefit Response DEPENDENT MIDDLE NAME

D | 2100D | N301 | - | 166 .............. 361

D | 2100D | N302 | - | 166 .............. 362
DEPENDENT BIRTH DATE

Dependent Middle Name

The middle name of the dependent.
Dependent Birth Date 270 - Eligibility Benefit Inquiry
The date of birth of the dependent. D | 2100D | NM105 | - | 1037 ............ 153
270 - Eligibility Benefit Inquiry 271 - Eligibility Benefit Response
D | 2100D | DMG02 | - | 1251 ............ 165 D | 2100D | NM105 |
DEPENDENT NAME SUFFIX
- | 1037 ............ 355
271 - Eligibility Benefit Response
D | 2100D | DMG02 | - | 1251 ............ 373
DEPENDENT CITY NAME

Dependent Name Suffix

A suffix following the name, including the
Dependent City Name generation of the patient, such as I, II, III, Jr, Sr.
The city name of the patient. 270 - Eligibility Benefit Inquiry
D | 2100D | NM107 | - | 1039 ............ 153
270 - Eligibility Benefit Inquiry
D | 2100D | N401 | - | 19 ................ 158 271 - Eligibility Benefit Response
D | 2100D | NM107 | - | 1039 ............ 356
271 - Eligibility Benefit Response DEPENDENT POSTAL ZONE OR ZIP CODE

D | 2100D |
DEPENDENT COUNTRY CODE
N401 | - | 19 ................ 364

Dependent Postal Zone or ZIP

Dependent Country Code Code
Country code of the dependent. The zip code of the dependent.
271 - Eligibility Benefit Response 270 - Eligibility Benefit Inquiry
D | 2100D |
DEPENDENT COUNTRY SUBDIVISION CODE
N404 | - | 26 ................ 364 D | 2100D | N403 | - | 116............... 159

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271 - Eligibility Benefit Response Diagnosis Code Pointer

D | 2100D |
DEPENDENT STATE CODE
N403 | - | 116............... 364 A pointer to the claim diagnosis code in the
order of importance to this service.
270 - Eligibility Benefit Inquiry
Dependent State Code D | 2110C | EQ05 | C004-1 | 1328 ............ 134
The state postal code of the dependent. D | 2110C | EQ05 | C004-2 | 1328 ............ 134
D | 2110C | EQ05 | C004-3 | 1328 ............ 135
270 - Eligibility Benefit Inquiry
D | 2110C | EQ05 | C004-4 | 1328 ............ 135
D | 2100D | N402 | - | 156 .............. 159
D | 2110D | EQ05 | C004-1 | 1328 ............ 191
271 - Eligibility Benefit Response D | 2110D | EQ05 | C004-2 | 1328 ............ 191
D | 2100D | N402 | - | 156 .............. 364 D | 2110D | EQ05 | C004-3 | 1328 ............ 191
DEPENDENT SUPPLEMENTAL IDENTIFIER

D | 2110D | EQ05 | C004-4 | 1328 ............ 191

271 - Eligibility Benefit Response
Dependent Supplemental D | 2110C | EB14 | C004-1 | 1328 ............ 307
Identifier D | 2110C | EB14 | C004-2 | 1328 ............ 307
D | 2110C | EB14 | C004-3 | 1328 ............ 307
Identifies another or additional distinguishing D | 2110C | EB14 | C004-4 | 1328 ............ 308
code number associated with the dependent. D | 2110D | EB14 | C004-1 | 1328 ............ 410
270 - Eligibility Benefit Inquiry D | 2110D | EB14 | C004-2 | 1328 ............ 410
D | 2100D | REF02 | - | 127 .............. 156 D | 2110D | EB14 | C004-3 | 1328 .............411
D | 2110D | EB14 | C004-4 | 1328 .............411
271 - Eligibility Benefit Response DIAGNOSIS TYPE CODE

D | 2100D | REF02 |
DESCRIPTION
- | 127 .............. 360
Diagnosis Type Code
Description Code identifying the type of diagnosis.
A free-form description to clarify the related data 270 - Eligibility Benefit Inquiry
elements and their content. D | 2100C | HI01 | C022-1 | 1270 .............114
D | 2100C | HI02 | C022-1 | 1270 .............115
271 - Eligibility Benefit Response D | 2100C | HI03 | C022-1 | 1270 .............116
D | 2100C | MPI04 | - | 352 .............. 287 D | 2100C | HI04 | C022-1 | 1270 .............117
D | 2100D | MPI04 |
DIAGNOSIS CODE
- | 352 .............. 391 D | 2100C | HI05 | C022-1 | 1270 .............118
D | 2100C | HI06 | C022-1 | 1270 .............119
D | 2100C | HI07 | C022-1 | 1270 ............ 120
Diagnosis Code D | 2100C | HI08 | C022-1 | 1270 ............ 121
D | 2100D | HI01 | C022-1 | 1270 ............ 171
An ICD-9-CM Diagnosis Code identifying a
D | 2100D | HI02 | C022-1 | 1270 ............ 172
diagnosed medical condition. D | 2100D | HI03 | C022-1 | 1270 ............ 173
270 - Eligibility Benefit Inquiry D | 2100D | HI04 | C022-1 | 1270 ............ 174
D | 2100C | HI01 | C022-2 | 1271 .............114 D | 2100D | HI05 | C022-1 | 1270 ............ 175
D | 2100C | HI02 | C022-2 | 1271 .............115 D | 2100D | HI06 | C022-1 | 1270 ............ 176
D | 2100C | HI03 | C022-2 | 1271 .............116 D | 2100D | HI07 | C022-1 | 1270 ............ 177
D | 2100C | HI04 | C022-2 | 1271 .............117 D | 2100D | HI08 | C022-1 | 1270 ............ 178
D | 2100C | HI05 | C022-2 | 1271 .............118
271 - Eligibility Benefit Response
D | 2100C | HI06 | C022-2 | 1271 .............119
D | 2100C | HI01 | C022-1 | 1270 ............ 275
D | 2100C | HI07 | C022-2 | 1271 ............ 120
D | 2100C | HI02 | C022-1 | 1270 ............ 276
D | 2100C | HI08 | C022-2 | 1271 ............ 121
D | 2100C | HI03 | C022-1 | 1270 ............ 277
D | 2100D | HI01 | C022-2 | 1271 ............ 171
D | 2100C | HI04 | C022-1 | 1270 ............ 278
D | 2100D | HI02 | C022-2 | 1271 ............ 172
D | 2100C | HI05 | C022-1 | 1270 ............ 279
D | 2100D | HI03 | C022-2 | 1271 ............ 173
D | 2100C | HI06 | C022-1 | 1270 ............ 280
D | 2100D | HI04 | C022-2 | 1271 ............ 174
D | 2100C | HI07 | C022-1 | 1270 ............ 281
D | 2100D | HI05 | C022-2 | 1271 ............ 175
D | 2100C | HI08 | C022-1 | 1270 ............ 282
D | 2100D | HI06 | C022-2 | 1271 ............ 176
D | 2100D | HI01 | C022-1 | 1270 ............ 379
D | 2100D | HI07 | C022-2 | 1271 ............ 177
D | 2100D | HI02 | C022-1 | 1270 ............ 380
D | 2100D | HI08 | C022-2 | 1271 ............ 178
D | 2100D | HI03 | C022-1 | 1270 ............ 381
271 - Eligibility Benefit Response D | 2100D | HI04 | C022-1 | 1270 ............ 382
D | 2100C | HI01 | C022-2 | 1271 ............ 275 D | 2100D | HI05 | C022-1 | 1270 ............ 383
D | 2100C | HI02 | C022-2 | 1271 ............ 276 D | 2100D | HI06 | C022-1 | 1270 ............ 384
D | 2100C | HI03 | C022-2 | 1271 ............ 277 D | 2100D | HI07 | C022-1 | 1270 ............ 385
D | 2100C | HI04 | C022-2 | 1271 ............ 278 D | 2100D
ELIGIBILITY OR BENEFIT DATE TIME PERIOD
| HI08 | C022-1 | 1270 ............ 386
D | 2100C | HI05 | C022-2 | 1271 ............ 279
D | 2100C | HI06 | C022-2 | 1271 ............ 280
D | 2100C | HI07 | C022-2 | 1271 ............ 281 Eligibility or Benefit Date Time
D | 2100C | HI08 | C022-2 | 1271 ............ 282
D | 2100D | HI01 | C022-2 | 1271 ............ 379 Period
D | 2100D | HI02 | C022-2 | 1271 ............ 380 Date or period associated with the eligibility or
D | 2100D | HI03 | C022-2 | 1271 ............ 381 benefit being described.
D | 2100D | HI04 | C022-2 | 1271 ............ 382
D | 2100D | HI05 | C022-2 | 1271 ............ 383
271 - Eligibility Benefit Response
D | 2110C | DTP03 | - | 1251 ............ 318
D | 2100D | HI06 | C022-2 | 1271 ............ 384
D | 2110D | DTP03 | - | 1251 ............ 421
D | 2100D | HI07 | C022-2 | 1271 ............ 385 ELIGIBILITY OR BENEFIT INFORMATION

D | 2100D
DIAGNOSIS CODE POINTER
| HI08 | C022-2 | 1271 ............ 386

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Eligibility or Benefit Information Free Form Message Text

Benefit status of the individual or benefit related Text used to convey information related to the
category to be further described in the transaction.
transaction.
271 - Eligibility Benefit Response
271 - Eligibility Benefit Response D | 2110C | MSG01 | - | 933 .............. 323
D | 2110C | EB01 | - | 1390 ............ 291 D | 2110D | MSG01 |
GOVERNMENT SERVICE AFFILIATION CODE
- | 933 .............. 426
D | 2110D |
EMPLOYMENT STATUS CODE
EB01 | - | 1390 ............ 395

Government Service Affiliation

Employment Status Code Code
A code used to define the employment status of Code specifying the government service
the individual covered by this insurance payer. affiliation.
271 - Eligibility Benefit Response 271 - Eligibility Benefit Response
D | 2100C | MPI02 | - | 584 .............. 286 D | 2100C | MPI03 | - | 1595 ............ 286
D | 2100D | MPI02 |
ENTITY IDENTIFIER CODE
- | 584 .............. 390 D | 2100D | MPI03 | - | 1595 ............ 390
HIERARCHICAL CHILD CODE

Entity Identifier Code Hierarchical Child Code

Code identifying an organizational entity, a Code indicating if there are hierarchical child
physical location, property or an individual. data segments subordinate to the level being
270 - Eligibility Benefit Inquiry described.
D | 2100A | NM101 | - | 98 .................. 69 270 - Eligibility Benefit Inquiry
D | 2100B | NM101 | - | 98 .................. 75 D | 2000A | HL04 | - | 736 ................ 68
D | 2100C | NM101 | - | 98 .................. 92 D | 2000B | HL04 | - | 736 ................ 74
D | 2100D | NM101 | - | 98 ................ 151 D | 2000C | HL04 | - | 736 ................ 89
271 - Eligibility Benefit Response D | 2000D | HL04 | - | 736 .............. 148
D | 2100A | NM101 | - | 98 ................ 218 271 - Eligibility Benefit Response
D | 2100B | NM101 | - | 98 ................ 232 D | 2000A | HL04 | - | 736 .............. 214
D | 2100C | NM101 | - | 98 ................ 249 D | 2000B | HL04 | - | 736 .............. 231
D | 2120C | NM101 | - | 98 ................ 330 D | 2000C | HL04 | - | 736 .............. 245
D | 2100D | NM101 | - | 98 ................ 354 D | 2000D | HL04 | - | 736 .............. 350
D | 2120D
ENTITY TYPE QUALIFIER
| NM101 | - | 98 ................ 433 HIERARCHICAL ID NUMBER

Hierarchical ID Number
Entity Type Qualifier
A unique number assigned by the sender to
Code qualifying the type of entity. identify a particular data segment in a
270 - Eligibility Benefit Inquiry hierarchical structure.
D | 2100A | NM102 | - | 1065 .............. 70
270 - Eligibility Benefit Inquiry
D | 2100B | NM102 | - | 1065 .............. 76
D | 2000A | HL01 | - | 628 ................ 67
D | 2100C | NM102 | - | 1065 .............. 93
D | 2000B | HL01 | - | 628 ................ 73
D | 2100D | NM102 | - | 1065 ............ 152
D | 2000C | HL01 | - | 628 ................ 88
271 - Eligibility Benefit Response D | 2000D | HL01 | - | 628 .............. 147
D | 2100A | NM102 | - | 1065 ............ 219
271 - Eligibility Benefit Response
D | 2100B | NM102 | - | 1065 ............ 233
D | 2000A | HL01 | - | 628 .............. 214
D | 2100C | NM102 | - | 1065 ............ 250
D | 2000B | HL01 | - | 628 .............. 230
D | 2120C | NM102 | - | 1065 ............ 331
D | 2000C | HL01 | - | 628 .............. 244
D | 2100D | NM102 | - | 1065 ............ 355
D | 2000D | HL01 | - | 628 .............. 348
D | 2120D
FOLLOW-UP ACTION CODE
| NM102 | - | 1065 ............ 434 HIERARCHICAL LEVEL CODE

Follow-up Action Code Hierarchical Level Code

Code defining the characteristic of a level in a
Code identifying follow-up actions allowed.
hierarchical structure.
271 - Eligibility Benefit Response
D | 2000A | AAA04 | - | 889 .............. 216
270 - Eligibility Benefit Inquiry
D | 2000A | HL03 | - | 735 ................ 67
D | 2100A | AAA04 | - | 889 .............. 228
D | 2000B | HL03 | - | 735 ................ 74
D | 2100B | AAA04 | - | 889 .............. 239
D | 2000C | HL03 | - | 735 ................ 89
D | 2100C | AAA04 | - | 889 .............. 264
D | 2000D | HL03 | - | 735 .............. 148
D | 2110C | AAA04 | - | 889 .............. 321
D | 2100D | AAA04 | - | 889 .............. 368 271 - Eligibility Benefit Response
D | 2110D
FREE FORM MESSAGE TEXT
| AAA04 | - | 889 .............. 424 D | 2000A | HL03 | - | 735 .............. 214
D | 2000B | HL03 | - | 735 .............. 231
D | 2000C | HL03 | - | 735 .............. 245
D | 2000D
HIERARCHICAL PARENT ID NUMBER
| HL03 | - | 735 .............. 349

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Hierarchical Parent ID Number D | 2100D | INS02 | - | 1069 ............ 168

Identification number of the next higher 271 - Eligibility Benefit Response

hierarchical data segment that the data D | 2100C | INS02 | - | 1069 ............ 272
segment being described is subordinate to. D | 2100D | INS02 |
INDUSTRY CODE
- | 1069 ............ 376

270 - Eligibility Benefit Inquiry

D | 2000B | HL02 | - | 734 ................ 73
D | 2000C | HL02 | - | 734 ................ 88
Industry Code
D | 2000D | HL02 | - | 734 .............. 148 Code indicating a code from a specific industry
code list.
271 - Eligibility Benefit Response
D | 2000B | HL02 | - | 734 .............. 230 270 - Eligibility Benefit Inquiry
D | 2000C | HL02 | - | 734 .............. 244 D | 2110C | III02 | - | 1271 ............ 140
D | 2000D |
HIERARCHICAL STRUCTURE CODE
HL02 | - | 734 .............. 349 D | 2110D | III02 | - | 1271 ............ 194
271 - Eligibility Benefit Response
D | 2115C | III02 | - | 1271 ............ 325
Hierarchical Structure Code D | 2115D |
INFORMATION RECEIVER ADDITIONAL ADDRESS LINE
III02 | - | 1271 ............ 428
Code indicating the hierarchical application
structure of a transaction set that utilizes the HL
segment to define the structure of the Information Receiver Additional
transaction set Address Line
270 - Eligibility Benefit Inquiry The Information Receiver’s additional address
H | | BHT01 | - | 1005 .............. 63 information.
271 - Eligibility Benefit Response 270 - Eligibility Benefit Inquiry
H |
IDENTIFICATION CODE QUALIFIER
| BHT01 | - | 1005 .............211 D | 2100B | N302 | - | 166 ................ 81
INFORMATION RECEIVER ADDITIONAL IDENTIFIER

Identification Code Qualifier Information Receiver

Code designating the system/method of code Additional Identifier
structure used for Identification Code (67).
Identifies another or additional distinguishing
270 - Eligibility Benefit Inquiry code number associated with the receiver of
D | 2100A | NM108 | - | 66 .................. 71 information.
D | 2100B | NM108 | - | 66 .................. 77
D | 2100C | NM108 | - | 66 .................. 95 270 - Eligibility Benefit Inquiry
D | 2100B | REF02 | - | 127 ................ 80
271 - Eligibility Benefit Response
D | 2100A | NM108 | - | 66 ................ 220 271 - Eligibility Benefit Response
D | 2100B | NM108 | - | 66 ................ 234 D | 2100B | REF02 |
INFORMATION RECEIVER ADDITIONAL IDENTIFIER STATE
- | 127 .............. 237
D | 2100C | NM108 | - | 66 ................ 251
D | 2120C | NM108 | - | 66 ................ 332
D | 2120D
IMPLEMENTATION CONVENTION REFERENCE
| NM108 | - | 66 ................ 435 Information Receiver
Additional Identifier State
Code indicating which state issued the identifier.
Implementation Convention
Reference 270 - Eligibility Benefit Inquiry
D | 2100B | REF03 | - | 352 ................ 80
Reference assigned to identify Implementation
Convention. 271 - Eligibility Benefit Response
D | 2100B | REF03 | - | 352 .............. 237
270 - Eligibility Benefit Inquiry INFORMATION RECEIVER ADDRESS LINE

H | | ST03 | - | 1705 .............. 62

271 - Eligibility Benefit Response Information Receiver Address
H |
IN PLAN NETWORK INDICATOR
| ST03 | - | 1705 ............ 210 Line
The Information Receiver’s address.
In Plan Network Indicator 270 - Eligibility Benefit Inquiry
A yes/no indicator that specifies whether or not D | 2100B |
INFORMATION RECEIVER CITY NAME
N301 | - | 166 ................ 81
services from the requested provider were
provided within the health plan network or not.
Information Receiver City Name
271 - Eligibility Benefit Response
D | 2110C | EB12 | - | 1073 ............ 303 The City Name of the Information Receiver’s
D | 2110D | EB12 | - | 1073 ............ 406 address.
INDIVIDUAL RELATIONSHIP CODE

270 - Eligibility Benefit Inquiry

D | 2100B |
INFORMATION RECEIVER FIRST NAME
N401 | - | 19 .................. 82
Individual Relationship Code
Code indicating the relationship between two
individuals or entities.
270 - Eligibility Benefit Inquiry
D | 2100C | INS02 | - | 1069 .............111

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Information Receiver First Information Receiver State

Name Code
The first name of the individual or organization The State Postal Code of the Information
who expects to receive information in response Receiver’s address.
to a query.
270 - Eligibility Benefit Inquiry
270 - Eligibility Benefit Inquiry D | 2100B |
INFORMATION SOURCE COMMUNICATION NUMBER
N402 | - | 156 ................ 83
D | 2100B | NM104 | - | 1036 .............. 76
271 - Eligibility Benefit Response
D | 2100B | NM104 | - | 1036 ............ 233 Information Source
INFORMATION RECEIVER IDENTIFICATION NUMBER

Communication Number
Contact number for the designated person or
Information Receiver entity for the information source.
Identification Number 271 - Eligibility Benefit Response
The identification number of the individual or D | 2100A | PER04 | - | 364 .............. 223
organization who expects to receive information D | 2100A | PER06 | - | 364 .............. 224
in response to a query. D | 2100A | PER08 |
INFORMATION SOURCE CONTACT NAME
- | 364 .............. 225

270 - Eligibility Benefit Inquiry

D | 2100B | NM109 | - | 67 .................. 78
Information Source Contact
271 - Eligibility Benefit Response
D | 2100B | NM109 | - | 67 ................ 235
Name
INFORMATION RECEIVER LAST OR ORGANIZATION NAME

Information source contact name to whom

inquiries about this transaction should be
Information Receiver Last or directed.
Organization Name 271 - Eligibility Benefit Response
D | 2100A | PER02 | - | 93 ................ 222
The name of the organization or last name of INFORMATION SOURCE FIRST NAME

the individual that expects to receive

information or is receiving information.
Information Source First Name
270 - Eligibility Benefit Inquiry First name of an individual who is the source of
D | 2100B | NM103 | - | 1035 .............. 76
the information.
271 - Eligibility Benefit Response
270 - Eligibility Benefit Inquiry
D | 2100B | NM103 | - | 1035 ............ 233
INFORMATION RECEIVER MIDDLE NAME
D | 2100A | NM104 | - | 1036 .............. 70
271 - Eligibility Benefit Response
Information Receiver Middle D | 2100A | NM104 |
INFORMATION SOURCE LAST OR ORGANIZATION NAME
- | 1036 ............ 219

Name
The middle name of the individual or Information Source Last or
organization who expects to receive information
in response to a query. Organization Name
The organization name or the last name of an
270 - Eligibility Benefit Inquiry individual who is the source of the information.
D | 2100B | NM105 | - | 1037 .............. 76
270 - Eligibility Benefit Inquiry
271 - Eligibility Benefit Response D | 2100A | NM103 | - | 1035 .............. 70
D | 2100B | NM105 |
INFORMATION RECEIVER NAME SUFFIX
- | 1037 ............ 234
271 - Eligibility Benefit Response
D | 2100A | NM103 |
INFORMATION SOURCE MIDDLE NAME
- | 1035 ............ 219
Information Receiver Name
Suffix
Information Source Middle
The suffix to the name of the individual or
organization who expects to receive information Name
in response to a query. Middle name of an individual who is the source
of the information.
270 - Eligibility Benefit Inquiry
D | 2100B | NM107 | - | 1039 .............. 77 270 - Eligibility Benefit Inquiry
D | 2100A | NM105 | - | 1037 .............. 70
271 - Eligibility Benefit Response
D | 2100B | NM107 |
INFORMATION RECEIVER POSTAL ZONE OR ZIP CODE
- | 1039 ............ 234 271 - Eligibility Benefit Response
D | 2100A | NM105 |
INFORMATION SOURCE NAME SUFFIX
- | 1037 ............ 219

Information Receiver Postal

Zone or ZIP Code Information Source Name Suffix
The Zip Code of the Information Receiver’s Suffix to the name of the individual who is the
address. source of the information.

270 - Eligibility Benefit Inquiry 270 - Eligibility Benefit Inquiry

D | 2100A | NM107 | - | 1039 .............. 71
D | 2100B |
INFORMATION RECEIVER STATE CODE
N403 | - | 116................. 83

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271 - Eligibility Benefit Response Maintenance Type Code

D | 2100A | NM107 |
INFORMATION SOURCE PRIMARY IDENTIFIER
- | 1039 ............ 220 Code identifying a specific type of item
maintenance
271 - Eligibility Benefit Response
Information Source Primary D | 2100C | INS03 | - | 875 .............. 272
Identifier D | 2100D | INS03 |
MILITARY SERVICE RANK CODE
- | 875 .............. 376
Identifies the number by which the information
source is known to the information receiver.
Military Service Rank Code
270 - Eligibility Benefit Inquiry
D | 2100A | NM109 | - | 67 .................. 71 Code specifying the military service rank.

271 - Eligibility Benefit Response 271 - Eligibility Benefit Response

D | 2100A | NM109 | - | 67 ................ 220 D | 2100C | MPI05 | - | 1596 ............ 287
INFORMATION STATUS CODE
D | 2100D | MPI05 |
PERIOD COUNT
- | 1596 ............ 391

Information Status Code

Period Count
A code to indicate the status of information.
Total number of periods.
271 - Eligibility Benefit Response
D | 2100C | MPI01 | - | 1201 ............ 285 271 - Eligibility Benefit Response
D | 2100D | MPI01 | - | 1201 ............ 389 D | 2110C | HSD06 | - | 616 ...............311
INJURED BODY PART NAME
D | 2110D | HSD06 |
PLAN COVERAGE DESCRIPTION
- | 616 .............. 414

Injured Body Part Name

Plan Coverage Description
Part of body affected by injury or illness
A description or number that identifies the plan
271 - Eligibility Benefit Response or coverage
D | 2115C | III04 | - | 933 .............. 327
D | 2115D | III04 | - | 933 .............. 430 271 - Eligibility Benefit Response
INSURANCE TYPE CODE
D | 2110C | EB05 | - | 1204 ............ 299
D | 2110D |
PLAN,, GROUP OR PLAN NETWORK NAME
EB05 | - | 1204 ............ 403
Insurance Type Code
Code identifying the type of insurance. Plan, Group or Plan Network
271 - Eligibility Benefit Response Name
D | 2110C | EB04 | - | 1336 ............ 298
D | 2110D | EB04 | - | 1336 ............ 402
Identifies the Plan, Group or Plan Network
INSURED INDICATOR
Name in association with the
Subscriber/Dependent Supplemental Identifier.
Insured Indicator 271 - Eligibility Benefit Response
D | 2100C | REF03 | - | 352 .............. 256
Indicates whether the insured is the subscriber
D | 2110C | REF03 | - | 352 .............. 316
or a dependent.
D | 2100D | REF03 | - | 352 .............. 360
270 - Eligibility Benefit Inquiry D | 2110D
PRIOR AUTHORIZATION OR REFERRAL NUMBER
| REF03 | - | 352 .............. 419
D | 2100C | INS01 | - | 1073 .............111
D | 2100D | INS01 | - | 1073 ............ 168
271 - Eligibility Benefit Response Prior Authorization or Referral
D | 2100C | INS01 | - | 1073 ............ 271 Number
D | 2100D | INS01 | - | 1073 ............ 376
LOOP IDENTIFIER CODE
A number, code or other value that indicates the
services provided on this claim have been
authorized by the payee or other service
Loop Identifier Code organization, or that a referral for services has
The loop ID number given on the transaction been approved.
set diagram is the value for this data element in
270 - Eligibility Benefit Inquiry
segments LS and LE. D | 2110C | REF02 | - | 127 .............. 143
271 - Eligibility Benefit Response D | 2110D | REF02 |
PROCEDURE CODE
- | 127 .............. 197
D | 2110C | LS01 | - | 447 .............. 328
D | 2110C | LE01 | - | 447 .............. 346
D | 2110D | LS01 | - | 447 .............. 431 Procedure Code
D | 2110D | LE01 | - | 447 .............. 449
MAINTENANCE REASON CODE
Code identifying the procedure, product or
service.
Maintenance Reason Code 270 - Eligibility Benefit Inquiry
D | 2110C | EQ02 | C003-2 | 234 .............. 131
Code identifying reason for the maintenance
D | 2110D | EQ02 | C003-2 | 234 .............. 188
change
271 - Eligibility Benefit Response
271 - Eligibility Benefit Response D | 2110C | EB13 | C003-2 | 234 .............. 305
D | 2100C | INS04 | - | 1203 ............ 272
D | 2110D | EB13 | C003-2 | 234 .............. 408
D | 2100D | INS04 |
MAINTENANCE TYPE CODE
- | 1203 ............ 377 PROCEDURE MODIFIER

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Procedure Modifier D | 2100D | PRV03 | - | 127 .............. 371

D | 2120D | PRV03 | - | 127 .............. 448
This identifies special circumstances related to QUANTITY QUALIFIER

the performance of the service.

270 - Eligibility Benefit Inquiry Quantity Qualifier
D | 2110C | EQ02 | C003-3 | 1339 ............ 132 Code specifying the type of quantity.
D | 2110C | EQ02 | C003-4 | 1339 ............ 132
D | 2110C | EQ02 | C003-5 | 1339 ............ 133 271 - Eligibility Benefit Response
D | 2110C | EQ02 | C003-6 | 1339 ............ 133 D | 2110C | EB09 | - | 673 .............. 301
D | 2110D | EQ02 | C003-3 | 1339 ............ 189 D | 2110C | HSD01 | - | 673 .............. 310
D | 2110D | EQ02 | C003-4 | 1339 ............ 189 D | 2110D | EB09 | - | 673 .............. 405
D | 2110D | EQ02 | C003-5 | 1339 ............ 190 D | 2110D
RECEIVER PROVIDER SPECIALTY CODE
| HSD01 | - | 673 .............. 413
D | 2110D | EQ02 | C003-6 | 1339 ............ 190
271 - Eligibility Benefit Response
D | 2110C | EB13 | C003-3 | 1339 ............ 305 Receiver Provider Specialty
D | 2110C | EB13 | C003-4 | 1339 ............ 305 Code
D | 2110C | EB13 | C003-5 | 1339 ............ 306
Identifies another or distinguishing number for a
D | 2110C | EB13 | C003-6 | 1339 ............ 306
provider.
D | 2110D | EB13 | C003-3 | 1339 ............ 408
D | 2110D | EB13 | C003-4 | 1339 ............ 409 271 - Eligibility Benefit Response
D | 2110D | EB13 | C003-5 | 1339 ............ 409 D | 2100B | PRV03 |
RECEIVER PROVIDER TAXONOMY CODE
- | 127 .............. 242
D | 2110D
PRODUCT OR SERVICE ID
| EB13 | C003-6 | 1339 ............ 409

Receiver Provider Taxonomy

Product or Service ID Code
Identifying number for a product or service. Code designating the provider type,
271 - Eligibility Benefit Response classification, and specialization.
D | 2110C | EB13 | C003-8 | 234 .............. 306
270 - Eligibility Benefit Inquiry
D | 2110D | EB13 | C003-8 | 234 .............. 410
PRODUCT OR SERVICE ID QUALIFIER
D | 2100B | PRV03 |
REFERENCE IDENTIFICATION QUALIFIER
- | 127 ................ 85

Product or Service ID Qualifier Reference Identification

Code identifying the type/source of the
descriptive number used in Product/Service ID
Qualifier
(234). Code qualifying the reference identification.
270 - Eligibility Benefit Inquiry 270 - Eligibility Benefit Inquiry
D | 2110C | EQ02 | C003-1 | 235 .............. 131 D | 2100B | REF01 | - | 128 ................ 79
D | 2110D | EQ02 | C003-1 | 235 .............. 188 D | 2100B | PRV02 | - | 128 ................ 85
D | 2100C | REF01 | - | 128 ................ 98
271 - Eligibility Benefit Response D | 2100C | PRV02 | - | 128 .............. 105
D | 2110C | EB13 | C003-1 | 235 .............. 304 D | 2110C | REF01 | - | 128 .............. 142
D | 2110D |
PROVIDER CODE
EB13 | C003-1 | 235 .............. 407 D | 2100D | REF01 | - | 128 .............. 154
D | 2100D | PRV02 | - | 128 .............. 162
D | 2110D | REF01 | - | 128 .............. 196
Provider Code 271 - Eligibility Benefit Response
Code identifying the type of provider. D | 2100B | REF01 | - | 128 .............. 236
D | 2100B | PRV02 | - | 128 .............. 242
270 - Eligibility Benefit Inquiry
D | 2100C | REF01 | - | 128 .............. 254
D | 2100B | PRV01 | - | 1221 .............. 84
D | 2100C | PRV02 | - | 128 .............. 266
D | 2100C | PRV01 | - | 1221 ............ 104
D | 2110C | REF01 | - | 128 .............. 315
D | 2100D | PRV01 | - | 1221 ............ 161
D | 2120C | PRV02 | - | 128 .............. 345
271 - Eligibility Benefit Response D | 2100D | REF01 | - | 128 .............. 358
D | 2100B | PRV01 | - | 1221 ............ 241 D | 2100D | PRV02 | - | 128 .............. 370
D | 2100C | PRV01 | - | 1221 ............ 266 D | 2110D | REF01 | - | 128 .............. 418
D | 2120C | PRV01 | - | 1221 ............ 344 D |
REJECT REASON CODE
2120D | PRV02 | - | 128 .............. 448
D | 2100D | PRV01 | - | 1221 ............ 370
D | 2120D
PROVIDER IDENTIFIER
| PRV01 | - | 1221 ............ 447
Reject Reason Code
Code assigned by issuer to identify reason for
Provider Identifier rejection.
Number assigned by the payer, regulatory
authority, or other authorized body or agency to 271 - Eligibility Benefit Response
D | 2000A | AAA03 | - | 901 .............. 216
identify the provider.
D | 2100A | AAA03 | - | 901 .............. 227
270 - Eligibility Benefit Inquiry D | 2100B | AAA03 | - | 901 .............. 239
D | 2100C | PRV03 | - | 127 .............. 106 D | 2100C | AAA03 | - | 901 .............. 263
D | 2100D | PRV03 | - | 127 .............. 163 D | 2110C | AAA03 | - | 901 .............. 320
D | 2100D | AAA03 | - | 901 .............. 367
271 - Eligibility Benefit Response D | 2110D | AAA03 | - | 901 .............. 423
D | 2100C | PRV03 | - | 127 .............. 267 SAMPLE SELECTION MODULUS

D | 2120C | PRV03 | - | 127 .............. 345

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Sample Selection Modulus 271 - Eligibility Benefit Response

To specify the sampling frequency in terms of a D | 2100C | DMG02 |
SUBSCRIBER CITY NAME
- | 1251 ............ 269
modulus of the Unit of Measure, e.g., every fifth
bag, every 1.5 minutes.
271 - Eligibility Benefit Response Subscriber City Name
D | 2110C | HSD04 | - | 1167..............311 The City Name of the insured individual or
D | 2110D | HSD04 |
SERVICE TYPE CODE
- | 1167............. 414 subscriber to the coverage.
270 - Eligibility Benefit Inquiry
D | 2100C | N401 | - | 19 ................ 101
Service Type Code
271 - Eligibility Benefit Response
Code identifying the classification of service. D | 2100C | N401 | - | 19 ................ 260
SUBSCRIBER COUNTRY CODE

270 - Eligibility Benefit Inquiry

D | 2110C | EQ01 | - | 1365 ............ 125
D | 2110D | EQ01 | - | 1365 ............ 182 Subscriber Country Code
271 - Eligibility Benefit Response The code identifying the country of the insured
D | 2110C | EB03 | - | 1365 ............ 293 or subscriber address.
D | 2110D | EB03 | - | 1365 ............ 397
SPEND DOWN AMOUNT
271 - Eligibility Benefit Response
D | 2100C |
SUBSCRIBER COUNTRY SUBDIVISION CODE
N404 | - | 26 ................ 260

Spend Down Amount

Dollar amount subscriber must pay or has paid Subscriber Country
toward cost of health care before benefits are
effective.
Subdivision Code
The country subdivision code of the insured or
270 - Eligibility Benefit Inquiry subscriber address.
D | 2110C | AMT02 |
SPEND DOWN TOTAL BILLED AMOUNT
- | 782 .............. 136
271 - Eligibility Benefit Response
D | 2100C |
SUBSCRIBER ELIGIBILITY OR BENEFIT IDENTIFIER
N407 | - | 1715 ............ 261
Spend Down Total Billed
Amount Subscriber Eligibility or Benefit
The sum of all original charges that will be
billed, or have been billed, for services related
Identifier
to the Spend Down Amount. Number associated with the subscriber for the
eligibility or benefit being described.
270 - Eligibility Benefit Inquiry
D | 2110C | AMT02 |
SUBMITTER TRANSACTION IDENTIFIER
- | 782 .............. 137 271 - Eligibility Benefit Response
D | 2110C | REF02 |
SUBSCRIBER FIRST NAME
- | 127 .............. 316

Submitter Transaction Identifier

Trace or control number assigned by the Subscriber First Name
originator of the transaction. The first name of the insured individual or
subscriber to the coverage.
270 - Eligibility Benefit Inquiry
H | | BHT03 | - | 127 ................ 64 270 - Eligibility Benefit Inquiry
D | 2100C | NM104 | - | 1036 .............. 93
271 - Eligibility Benefit Response
H |
SUBSCRIBER ADDRESS LINE
| BHT03 | - | 127 .............. 212 271 - Eligibility Benefit Response
D | 2100C | NM104 |
SUBSCRIBER GENDER CODE
- | 1036 ............ 250

Subscriber Address Line

Address line of the current mailing address of
Subscriber Gender Code
the insured individual or subscriber to the Code indicating the sex of the subscriber to the
coverage. indicated coverage or policy.
270 - Eligibility Benefit Inquiry 270 - Eligibility Benefit Inquiry
D | 2100C | N301 | - | 166 .............. 100 D | 2100C | DMG03 | - | 1068 ............ 109
D | 2100C | N302 | - | 166 .............. 100 271 - Eligibility Benefit Response
271 - Eligibility Benefit Response D | 2100C | DMG03 |
SUBSCRIBER LAST NAME
- | 1068 ............ 269
D | 2100C | N301 | - | 166 .............. 257
D | 2100C |
SUBSCRIBER BIRTH DATE
N302 | - | 166 .............. 258
Subscriber Last Name
The surname of the insured individual or
Subscriber Birth Date subscriber to the coverage.
The date of birth of the subscriber to the 270 - Eligibility Benefit Inquiry
indicated coverage or policy. D | 2100C | NM103 | - | 1035 .............. 93
270 - Eligibility Benefit Inquiry 271 - Eligibility Benefit Response
D | 2100C | DMG02 | - | 1251 ............ 108 D | 2100C | NM103 | - | 1035 ............ 250
SUBSCRIBER MIDDLE NAME OR INITIAL

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Subscriber Middle Name or D | 2110C | HSD05 | - | 615 ...............311

D | 2110D | EB06 | - | 615 .............. 403
Initial D | 2110D | HSD05 | - | 615 .............. 414
TRACE ASSIGNING ENTITY ADDITIONAL IDENTIFIER

The middle name or initial of the subscriber to

the indicated coverage or policy.
270 - Eligibility Benefit Inquiry Trace Assigning Entity
D | 2100C | NM105 | - | 1037 .............. 94 Additional Identifier
271 - Eligibility Benefit Response Additional identifier for the entity assigning the
D | 2100C | NM105 | - | 1037 ............ 250 trace number.
SUBSCRIBER NAME SUFFIX

270 - Eligibility Benefit Inquiry

D | 2000C | TRN04 | - | 127 ................ 91
Subscriber Name Suffix D | 2000D | TRN04 | - | 127 .............. 150
Suffix of the insured individual or subscriber to 271 - Eligibility Benefit Response
the coverage. D | 2000C | TRN04 | - | 127 .............. 248
270 - Eligibility Benefit Inquiry D | 2000D | TRN04 |
TRACE ASSIGNING ENTITY IDENTIFIER
- | 127 .............. 353
D | 2100C | NM107 | - | 1039 .............. 94
271 - Eligibility Benefit Response
D | 2100C | NM107 | - | 1039 ............ 251
Trace Assigning Entity Identifier
Identifies the organization assigning the trace
SUBSCRIBER POSTAL ZONE OR ZIP CODE

number.
Subscriber Postal Zone or ZIP 270 - Eligibility Benefit Inquiry
Code D | 2000C | TRN03 | - | 509 ................ 91
D | 2000D | TRN03 | - | 509 .............. 150
The ZIP Code of the insured individual or
subscriber to the coverage. 271 - Eligibility Benefit Response
D | 2000C | TRN03 | - | 509 .............. 248
270 - Eligibility Benefit Inquiry D | 2000D | TRN03 | - | 509 .............. 353
D | 2100C | N403 | - | 116............... 102 TRACE NUMBER

271 - Eligibility Benefit Response

D | 2100C |
SUBSCRIBER PRIMARY IDENTIFIER
N403 | - | 116............... 260 Trace Number
Identification number used by originator of the
transaction.
Subscriber Primary Identifier
270 - Eligibility Benefit Inquiry
Primary identification number of the subscriber D | 2000C | TRN02 | - | 127 ................ 91
to the coverage. D | 2000D | TRN02 | - | 127 .............. 150
270 - Eligibility Benefit Inquiry 271 - Eligibility Benefit Response
D | 2100C | NM109 | - | 67 .................. 96 D | 2000C | TRN02 | - | 127 .............. 248
271 - Eligibility Benefit Response D | 2000D | TRN02 |
TRACE TYPE CODE
- | 127 .............. 353
D | 2100C | NM109 |
SUBSCRIBER STATE CODE
- | 67 ................ 252

Trace Type Code

Subscriber State Code Code identifying the type of re-association
The State Postal Code of the insured individual which needs to be performed.
or subscriber to the coverage. 270 - Eligibility Benefit Inquiry
270 - Eligibility Benefit Inquiry D | 2000C | TRN01 | - | 481 ................ 90
D | 2100C | N402 | - | 156 .............. 102 D | 2000D | TRN01 | - | 481 .............. 149

271 - Eligibility Benefit Response 271 - Eligibility Benefit Response

D | 2100C | N402 | - | 156 .............. 260 D | 2000C | TRN01 | - | 481 .............. 247
SUBSCRIBER SUPPLEMENTAL IDENTIFIER
D | 2000D | TRN01 |
TRANSACTION SEGMENT COUNT
- | 481 .............. 352

Subscriber Supplemental
Transaction Segment Count
Identifier
A tally of all segments between the ST and the
Identifies another or additional distinguishing SE segments including the ST and SE
code number associated with the subscriber. segments.
270 - Eligibility Benefit Inquiry 270 - Eligibility Benefit Inquiry
D | 2100C | REF02 | - | 127 ................ 99 D | | SE01 | - | 96 ................ 200
271 - Eligibility Benefit Response 271 - Eligibility Benefit Response
D | 2100C | REF02 |
TIME PERIOD QUALIFIER
- | 127 .............. 256 D | | SE01 | - | 96 ................ 450
TRANSACTION SET CONTROL NUMBER

Time Period Qualifier

Code defining the type of time period.
271 - Eligibility Benefit Response
D | 2110C | EB06 | - | 615 .............. 299

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Transaction Set Control Transaction Set Purpose Code

Number Code identifying purpose of transaction set.
The unique identification number within a 270 - Eligibility Benefit Inquiry
transaction set. H | | BHT02 | - | 353 ................ 64
270 - Eligibility Benefit Inquiry 271 - Eligibility Benefit Response
H | | ST02 | - | 329 ................ 61 H | | BHT02 | - | 353 ...............211
TRANSACTION TYPE CODE

D | | SE02 | - | 329 .............. 200

271 - Eligibility Benefit Response
H | | ST02 | - | 329 .............. 209 Transaction Type Code
D |
TRANSACTION SET CREATION DATE
| SE02 | - | 329 .............. 450 Code specifying the type of transaction.
270 - Eligibility Benefit Inquiry
H | | BHT06 | - | 640 ................ 65
Transaction Set Creation Date UNIT OR BASIS FOR MEASUREMENT CODE

Identifies the date the submitter created the

transaction. Unit or Basis for Measurement
270 - Eligibility Benefit Inquiry Code
H | | BHT04 | - | 373 ................ 64
Code specifying the units in which a value is
271 - Eligibility Benefit Response being expressed, or manner in which a
H |
TRANSACTION SET CREATION TIME
| BHT04 | - | 373 .............. 212 measurement has been taken.
271 - Eligibility Benefit Response
D | 2110C | HSD03 | - | 355 .............. 310
Transaction Set Creation Time D | 2110D | HSD03 | - | 355 .............. 413
VALID REQUEST INDICATOR

Time file is created for transmission.

270 - Eligibility Benefit Inquiry
H | | BHT05 | - | 337 ................ 65 Valid Request Indicator
Code indicating if the information request or
271 - Eligibility Benefit Response
H | | BHT05 | - | 337 .............. 212
portion of the request is valid or invalid.
TRANSACTION SET IDENTIFIER CODE

271 - Eligibility Benefit Response

D | 2000A | AAA01 | - | 1073 ............ 215
Transaction Set Identifier Code D | 2100A | AAA01 | - | 1073 ............ 226
D | 2100B | AAA01 | - | 1073 ............ 238
Code uniquely identifying a Transaction Set. D | 2100C | AAA01 | - | 1073 ............ 262
270 - Eligibility Benefit Inquiry D | 2110C | AAA01 | - | 1073 ............ 319
H | | ST01 | - | 143 ................ 61 D | 2100D | AAA01 | - | 1073 ............ 366
D | 2110D | AAA01 | - | 1073 ............ 422
271 - Eligibility Benefit Response
H |
TRANSACTION SET PURPOSE CODE
| ST01 | - | 143 .............. 209

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E.14 APRIL 2008