Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 270/271 | TR3 ID: 005010X279

Example 2b: 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.

Transmission Explanation

ST*271*4322*005010X279A1~

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

Transaction Set Control Number = 4322

Implementation Convention Reference = 005010X279A1

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*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

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*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*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 Number)

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*0~

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

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)

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*28*4322~

Number of Included Segments = 28

Transaction Set Control Number = 4322