Example 1c: Error Response from Payer to Clinic Not Eligible for Inquiries with Payer

Transmission Explanation

ST*271*4323*005010X279A1~

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

Transaction Set Control Number = 4323

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

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)

SE*8*4323~

Number of Included Segments = 8

Transaction Set Control Number = 4323