270

Eligibility, Coverage or Benefit Inquiry

Functional Group=HS

This Draft Standard for Trial Use 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.

Not Defined:

	Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
		ISA	Interchange Control Header	M	1			Required
		GS	Functional Group Header	M	1			Required

Heading:

	Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
	010	ST	Transaction Set Header	M	1			Required
	020	BHT	Beginning of Hierarchical Transaction	M	1			Required

Detail:

	Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
LOOP ID - 2000A						>1
	010	HL	Information Source Level	M	1			Required
LOOP ID - 2100A						1
	030	NM1	Information Source Name	M	1			Required

LOOP ID - 2000B						>1
	010	HL	Information Receiver Level	M	1			Required
LOOP ID - 2100B						1
	030	NM1	Information Receiver Name	M	1			Required
	040	REF	Information Receiver Additional Identification	O	9			Situational
	060	N3	Information Receiver Address	O	1			Situational
	070	N4	Information Receiver City/State/ZIP Code	O	1			Situational
	080	PER	Information Receiver Contact Information	O	3			Situational
	090	PRV	Information Receiver Provider Information	O	1			Situational

LOOP ID - 2000C						>1
	010	HL	Subscriber Level	M	1			Required
	020	TRN	Subscriber Trace Number	O	2		N2/020	Situational
LOOP ID - 2100C						1
	030	NM1	Subscriber Name	M	1			Required
	040	REF	Subscriber Additional Identification	O	9			Situational
	060	N3	Subscriber Address	O	1			Situational
	070	N4	Subscriber City/State/ZIP Code	O	1			Situational
	090	PRV	Provider Information	O	1			Situational
	100	DMG	Subscriber Demographic Information	O	1			Situational
	110	INS	Subscriber Relationship	O	1			Situational
	120	DTP	Subscriber Date	O	2			Situational
LOOP ID - 2110C						99
	130	EQ	Subscriber Eligibility or Benefit Inquiry Information	O	1			Situational
	135	AMT	Subscriber Spend Down Amount	O	1			Situational
	170	III	Subscriber Eligibility or Benefit Additional Inquiry Information	O	10			Situational
	190	REF	Subscriber Additional Information	O	1			Situational
	200	DTP	Subscriber Eligibility/Benefit Date	O	1			Situational

LOOP ID - 2000D						>1
	010	HL	Dependent Level	O	1			Situational
	020	TRN	Dependent Trace Number	O	2		N2/020	Situational
LOOP ID - 2100D						1
	030	NM1	Dependent Name	M	1			Required
	040	REF	Dependent Additional Identification	O	9			Situational
	060	N3	Dependent Address	O	1			Situational
	070	N4	Dependent City/State/ZIP Code	O	1			Situational
	090	PRV	Provider Information	O	1			Situational
	100	DMG	Dependent Demographic Information	O	1			Situational
	110	INS	Dependent Relationship	O	1			Situational
	120	DTP	Dependent Date	O	2			Situational
LOOP ID - 2110D						99
	130	EQ	Dependent Eligibility or Benefit Inquiry Information	O	1			Required
	170	III	Dependent Eligibility or Benefit Additional Inquiry Information	O	10			Situational
	190	REF	Dependent Additional Information	O	1			Situational
	200	DTP	Dependent Eligibility/Benefit Date	O	1			Situational
	210	SE	Transaction Set Trailer	M	1			Required

Not Defined:

	Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
		GE	Functional Group Trailer	M	1			Required
		IEA	Interchange Control Trailer	M	1			Required

Notes:

2/020	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.
2/020	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.

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