Example 1b: Response to a Generic Request by a Clinic for the Patient’s (Subscriber) Eligibility

Transmission Explanation

ST*271*4321*005010X279A1~

Transaction Set ID Code = 271 (Eligibility, Coverage or Benefit Information)

Transaction Set Control Number = 4321

Implementation Convention Reference = 005010X279A1

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*842610001~

Entity Identifier Code = PR (Payer)

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 (Information Receiver)

Hierarchical Child Code = 1

NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~

Entity Identifier Code = 1P (Provider)

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

NM1*IL*1*SMITH*JOHN****MI*123456789~

Entity Identifier Code = IL (Insured or Subscriber)

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)

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)

EB*B**1>33>35>47>86>88>98>AL>MH>UC*HM*GOLD 123 PLAN*27*10*****Y~

Eligibility or Benefit Information Code = B (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)

EB*B**1>33>35>47>86>88>98>AL>MH>UC*HM*GOLD 123 PLAN*27*30*****N~

Eligibility or Benefit Information Code = B (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)

LS*2120~

Loop Identifier Code = 2120

NM1*P3*1*JONES*MARCUS****SV*0202034~

Entity Identifier Code = P3 (Primary Care Provider)

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

SE*22*4321~

Number of Included Segments = 22

Transaction Set Control Number = 4321