Dependent Eligibility or Benefit Inquiry Information

Pos: 130

Max: 1

Detail - Optional

Loop: 2110D

Elements: 4

User Option (Usage): Required

To specify inquired eligibility or benefit information

Element Summary:

	Ref	Id	Element Name	Req	Type	Min/Max	Usage
	EQ01	1365	Service Type Code Description: Code identifying the classification of service An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of “30" (Health Benefit Plan Coverage) in EQ01. An information source may support the use of Service Type Codes from the list other than “30" (Health Benefit Plan Coverage) in EQ01 at their discretion. If an information source supports codes in addition to ”30", the information source may provide a list of the supported codes from the list below to the information receiver. If no list is provided, an information receiver may transmit the most appropriate code. If an inquiry is submitted with a Service Type Code from the list other than “30" and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of ”30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.3.6 for additional information. Not used if EQ02 is used.	C	ID	1/2	Situational

Code

Name

Medical Care

Surgical

Consultation

Diagnostic X-Ray

Diagnostic Lab

Radiation Therapy

Anesthesia

Surgical Assistance

Other Medical

Blood Charges

Used Durable Medical Equipment

Durable Medical Equipment Purchase

Ambulatory Service Center Facility

Renal Supplies in the Home

Alternate Method Dialysis

Chronic Renal Disease (CRD) Equipment

Pre-Admission Testing

Durable Medical Equipment Rental

Pneumonia Vaccine

Second Surgical Opinion

Third Surgical Opinion

Social Work

Diagnostic Dental

Periodontics

Restorative

Endodontics

Maxillofacial Prosthetics

Adjunctive Dental Services

Health Benefit Plan Coverage

If only a single category of inquiry can be supported, use this code.

Plan Waiting Period

Chiropractic

Chiropractic Office Visits

Dental Care

Dental Crowns

Dental Accident

Orthodontics

Prosthodontics

Oral Surgery

Routine (Preventive) Dental

Home Health Care

Home Health Prescriptions

Home Health Visits

Hospice

Respite Care

Hospital

Hospital - Inpatient

Hospital - Room and Board

Hospital - Outpatient

Hospital - Emergency Accident

Hospital - Emergency Medical

Hospital - Ambulatory Surgical

Long Term Care

Major Medical

Medically Related Transportation

Air Transportation

Cabulance

Licensed Ambulance

General Benefits

In-vitro Fertilization

MRI/CAT Scan

Donor Procedures

Acupuncture

Newborn Care

Pathology

Smoking Cessation

Well Baby Care

Maternity

Transplants

Audiology Exam

Inhalation Therapy

Diagnostic Medical

Private Duty Nursing

Prosthetic Device

Dialysis

Otological Exam

Chemotherapy

Allergy Testing

Immunizations

Routine Physical

Family Planning

Infertility

Abortion

AIDS

Emergency Services

Cancer

Pharmacy

Free Standing Prescription Drug

Mail Order Prescription Drug

Brand Name Prescription Drug

Generic Prescription Drug

Podiatry

Podiatry - Office Visits

Podiatry - Nursing Home Visits

Professional (Physician)

Anesthesiologist

Professional (Physician) Visit - Office

Professional (Physician) Visit - Inpatient

Professional (Physician) Visit - Outpatient

Professional (Physician) Visit - Nursing Home

Professional (Physician) Visit - Skilled Nursing Facility

Professional (Physician) Visit - Home

Psychiatric

Psychiatric - Room and Board

Psychotherapy

Psychiatric - Inpatient

Psychiatric - Outpatient

Rehabilitation

Rehabilitation - Room and Board

Rehabilitation - Inpatient

Rehabilitation - Outpatient

Occupational Therapy

Physical Medicine

Speech Therapy

Skilled Nursing Care

Skilled Nursing Care - Room and Board

Substance Abuse

Alcoholism

Drug Addiction

Vision (Optometry)

Frames

Routine Exam

Lenses

Nonmedically Necessary Physical

Experimental Drug Therapy

Independent Medical Evaluation

Partial Hospitalization (Psychiatric)

Day Care (Psychiatric)

Cognitive Therapy

Massage Therapy

Pulmonary Rehabilitation

Cardiac Rehabilitation

Pediatric

Nursery

Skin

Orthopedic

Cardiac

Lymphatic

Gastrointestinal

Endocrine

Neurology

Eye

Invasive Procedures

	EQ02	C003	Composite Medical Procedure Identifier Description: To identify a medical procedure by its standardized codes and applicable modifiers An information source may support the use of EQ02 - Composite Medical Procedure Identifier at their discretion. The EQ02 allows for a very specific inquiry, such as one based on a procedure code. Additional information such as diagnosis codes and place of service can be supplied in the III segment of loop 2110D. If an inquiry is submitted with EQ02 and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of “30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.3.6 for additional information. Not used if EQ01 is used.	C	Comp		Situational
		235	Product/Service ID Qualifier Description: Code identifying the type/source of the descriptive number used in Product/Service ID (234) Industry: Product or Service ID Qualifier Use this code to qualify the type of specific Product/Service ID that will be used in EQ02-2.	M	ID	2/2	Required

Code

Name

American Dental Association Codes

CODE SOURCE:

135: American Dental Association Codes

Current Procedural Terminology (CPT) Codes

CODE SOURCE:

133: Current Procedural Terminology (CPT) Codes

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

CODE SOURCE:

130: Health Care Financing Administration Common Procedural Coding System

International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure

CODE SOURCE:

131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE:

513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

National Drug Code in 5-4-2 Format

CODE SOURCE:

240: National Drug Code by Format

Mutually Defined

NOT ADVISED
Use this code only for local codes or interim uses until an appropriate new code is approved.

234

Product/Service ID
Description: Identifying number for a product or service
Industry: Procedure Code
Use this number for the product/service ID as identified by the preceding data element (EQ02-1).

1/48

Required

	ExternalCodeList
	Name: 130
	Description: Health Care Financing Administration Common Procedural Coding System

	ExternalCodeList
	Name: 131
	Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure

	ExternalCodeList
	Name: 133
	Description: Current Procedural Terminology (CPT) Codes

	ExternalCodeList
	Name: 135
	Description: American Dental Association Codes

	ExternalCodeList
	Name: 240
	Description: National Drug Code by Format

	ExternalCodeList
	Name: 513
	Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List

	1339	Procedure Modifier Description: This identifies special circumstances related to the performance of the service, as defined by trading partners Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.	O	AN	2/2	Situational
	1339	Procedure Modifier Description: This identifies special circumstances related to the performance of the service, as defined by trading partners Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.	O	AN	2/2	Situational
	1339	Procedure Modifier Description: This identifies special circumstances related to the performance of the service, as defined by trading partners Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.	O	AN	2/2	Situational
	1339	Procedure Modifier Description: This identifies special circumstances related to the performance of the service, as defined by trading partners Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.	O	AN	2/2	Situational
EQ03	1207	Coverage Level Code Description: Code indicating the level of coverage being provided for this insured Industry: Benefit Coverage Level Code Use EQ03 when an information source supports or may be thought to support the function of identifying benefits by the Benefit Coverage Level Code. Use this code to identify the types and number of entities that the request is to apply to. If not supported, the information source will process without this data element.	O	ID	3/3	Situational

	Code	Name
	CHD	Children Only
	DEP	Dependents Only
	ECH	Employee and Children
	EMP	Employee Only
	ESP	Employee and Spouse
	FAM	Family
	IND	Individual
	SPC	Spouse and Children
	SPO	Spouse Only

EQ04

1336

Insurance Type Code
Description: Code identifying the type of insurance policy within a specific insurance program
Use this code to identify the specific type of insurance the inquiry applies to if the information source has multiple insurance lines that apply to the person being inquired about. Do not use if the insurance type can be determined either by the person’s identifiers or the information source’s identifiers.

1/3

Situational

	Code	Name
	AP	Auto Insurance Policy
	C1	Commercial
	CO	Consolidated Omnibus Budget Reconciliation Act (COBRA)
	GP	Group Policy
	HM	Health Maintenance Organization (HMO)
	IP	Individual Policy
	OT	Other
	PR	Preferred Provider Organization (PPO)
	PS	Point of Service (POS)
	SP	Supplemental Policy
	WC	Workers Compensation

1.	R0102 - At least one of EQ01,EQ02 is required

Notes:

1. Use this segment to begin the eligibility/benefit inquiry looping structure.
2. If the EQ segment is used, either EQ01 - Service Type Code or EQ02 -Composite Medical Procedure Identifier must be used. Only EQ01 or EQ02 is to be sent, not both. An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of “30" (Health Benefit Plan Coverage) in EQ01. An information source may support the use of Service Type Codes other than ”30" (Health Benefit Plan Coverage) in EQ01 at their discretion. An information source may support the use of EQ02 - Composite Medical Procedure Identifier at their discretion. The EQ02 allows for a very specific inquiry, such as one based on a procedure code. Additional information such as diagnosis codes and place of service can be supplied in the III segment of loop 2100D.
3. If an inquiry is submitted with either a Service Type Code other than “30" in EQ01 or uses EQ02 and the information source does not support either of these levels of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of ”30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.3.6 for additional information.

Example:

EQ*30**FAM*GP~