Can you please provide clarification on the appropriate method for representing the primary care provider (PCP) effective date within the X12 271 Health Care Eligibility Benefit Response transaction?
Specifically, I would like to know:
- Is there a standard segment or data element within the 271 response that supports the inclusion of a PCP effective date?
- If so, could you please provide guidance on the correct usage and placement of this information within the transaction structure?
- If not explicitly supported, are there any recommended workarounds or implementation best practices for conveying this date in a compliant manner?
Specifically, is there a place to return a primary care provider effective date in the 271 response when the primary care provider is returned in the 2120 C/D loops? A DTP segment is not available in the 2120 C/D loops in the 005010 version of the guide.
Thank you for your submission. Currently there is a way to partially advise of the PCP effective dates, but it will depend on the payer’s ability to support, not knowing if the payer uses the DTP02 code values differently for different use cases. The partially explicit way to indicate would use EB01 = L, DTP01 = 295, and 2120 NM101 = P3.
There are several ways that would be recommended to advise of the primary care provider’s effective dates, but it will depend on the payer’s use of some of the values for other business purposes and their reuse of the DTP01 code values vs. unique use. For example, it is possible to use codes in the DTP01 – Period Start, Period End – however, if those values are used in other scenarios unrelated to this use case, it may be confusing to the provider receiving the 271. Therefore, a couple of options have been provided below to assess for best fit.
It is most important that when trying to identify whether a PCP applies to the member’s plan or benefits, that it be done using the EB01 = L (Primary Care Provider) and EB03 = 30 (Health Benefit Plan Level) to apply globally to the plan, or EB01 = a service-based or benefit-based code when the PCP applies to the benefit/service only.
This then allows the 2110C/D loops to be packaged together such that the 2110C/D EB01 + 2110C/D EB03 + 2110C/D DTP + 2120C/D LS/LS + NM1 all are tied together.
Example to represent current date that does not have an end dated PCP at a plan level.
EB*L**30~
DTP*193*D8*20251001~ (Period Start)
LS*2120~
NM1*P3*1*LAST NAME*FIRST NAME***M.D.~
PER*IC*NAME*TE*PHONE NUMBER~
N3*STREET ADDRESS~
N4*CITY*STATE*ZIP~
LE*2120~
or
EB*L**30~
DTP*295*D8*20251001~ (Primary Care Provider)
LS*2120~
NM1*P3*1*LAST NAME*FIRST NAME***M.D.~
PER*IC*NAME*TE*PHONE NUMBER~
N3*STREET ADDRESS~
N4*CITY*STATE*ZIP~
LE*2120~
Example to represent a date range that may have an end dated PCP at a plan level.
EB*L**30~
DTP*193*D8*20250901~ (Period Start)
DTP*194*D8*20250930~ (Period End)
LS*2120~
NM1*P3*1*LAST NAME*FIRST NAME***M.D.~
PER*IC*NAME*TE*PHONE NUMBER~
N3*STREET ADDRESS~
N4*CITY*STATE*ZIP~
LE*2120~
or
EB*L**30~
DTP*295*RD8*20250901-20250930~ (Primary Care Provider)
LS*2120~
NM1*P3*1*LAST NAME*FIRST NAME***M.D.~
PER*IC*NAME*TE*PHONE NUMBER~
N3*STREET ADDRESS~
N4*CITY*STATE*ZIP~
LE*2120~
Example to represent current date that does not have an end dated PCP at a benefit level.
EB*L**69~
DTP*193*D8*20251001~ (Period Start)
LS*2120~
NM1*P3*1*OB GYN LAST NAME*FIRST NAME***M.D.~
PER*IC*NAME*TE*PHONE NUMBER~
N3*STREET ADDRESS~
N4*CITY*STATE*ZIP~
LE*2120~
or
EB*L**69~
DTP*295*D8*20251001~ (Primary Care Provider)
LS*2120~
NM1*P3*1*OB GYN LAST NAME*FIRST NAME***M.D.~
PER*IC*NAME*TE*PHONE NUMBER~
N3*STREET ADDRESS~
N4*CITY*STATE*ZIP~
LE*2120~
Example to represent a date range that may have an end dated PCP at a benefit level.
EB*L**69~
DTP*193*D8*20250901~ (Period Start)
DTP*194*D8*20250930~ (Period End)
LS*2120~
NM1*P3*1*OB GYN LAST NAME*FIRST NAME***M.D.~
PER*IC*NAME*TE*PHONE NUMBER~
N3*STREET ADDRESS~
N4*CITY*STATE*ZIP~
LE*2120~
or
EB*L**30~
DTP*295*RD8*20250901-20250930~ (Primary Care Provider)
LS*2120~
NM1*P3*1*OB GYN LAST NAME*FIRST NAME***M.D.~
PER*IC*NAME*TE*PHONE NUMBER~
N3*STREET ADDRESS~
N4*CITY*STATE*ZIP~
LE*2120~