271

Eligibility, Coverage or Benefit Information

Functional Group=HB

This Draft Standard for Trial Use contains the format and establishes the data contents of the Eligibility, Coverage or Benefit Information Transaction Set (271) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to communicate information about or changes to eligibility, coverage or benefits from information sources (such as - insurers, sponsors, payors) to information receivers (such as - physicians, hospitals, repair facilities, third party administrators, governmental agencies). This information includes but is not limited to: benefit status, explanation of benefits, coverages, dependent coverage level, effective dates, amounts for co-insurance, co-pays, deductibles, exclusions and limitations.

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

         

 

025

AAA

Request Validation

O

9

 

 

Situational

         

LOOP ID - 2100A

 

 

1

 

 

 

 

 

 

 

 

030

NM1

Information Source Name

O

1

 

 

Required

         

 

040

REF

Information Source Additional Identification

O

9

 

 

Situational

         

 

080

PER

Information Source Contact Information

O

3

 

 

Situational

         

 

085

AAA

Request Validation

O

9

 

 

Situational

         

LOOP ID - 2000B

 

 

>1

 

 

 

 

 

 

 

 

010

HL

Information Receiver Level

O

1

 

 

Situational

         

LOOP ID - 2100B

 

 

1

 

 

 

 

 

 

 

 

030

NM1

Information Receiver Name

O

1

 

 

Required

         

 

040

REF

Information Receiver Additional Identification

O

9

 

 

Situational

         

 

085

AAA

Information Receiver Request Validation

O

9

 

 

Situational

         

LOOP ID - 2000C

 

 

>1

 

 

 

 

 

 

 

 

010

HL

Subscriber Level

O

1

 

 

Situational

         

 

020

TRN

Subscriber Trace Number

O

3

 

N2/020

Situational

         

LOOP ID - 2100C

 

 

1

 

 

 

 

 

 

 

 

030

NM1

Subscriber Name

O

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

         

 

080

PER

Subscriber Contact Information

O

3

 

 

Situational

         

 

085

AAA

Subscriber Request Validation

O

9

 

 

Situational

         

 

100

DMG

Subscriber Demographic Information

O

1

 

 

Situational

         

 

110

INS

Subscriber Relationship

O

1

 

 

Situational

         

 

120

DTP

Subscriber Date

O

9

 

 

Situational

         

LOOP ID - 2110C

 

 

>1

 

 

 

 

 

 

 

 

130

EB

Subscriber Eligibility or Benefit Information

O

1

 

 

Situational

         

 

135

HSD

Health Care Services Delivery

O

9

 

 

Situational

         

 

140

REF

Subscriber Additional Identification

O

9

 

 

Situational

         

 

150

DTP

Subscriber Eligibility/Benefit Date

O

20

 

 

Situational

         

 

160

AAA

Subscriber Request Validation

O

9

 

 

Situational

         

 

250

MSG

Message Text

O

10

 

 

Not recommended

         

LOOP ID - 2115C

 

 

10

 

 

 

 

 

 

 

 

260

III

Subscriber Eligibility or Benefit Additional Information

O

1

 

 

Situational

         

LOOP ID - LS

 

 

1

 

 

 

 

 

 

 

 

330

LS

Loop Header

O

1

 

 

Situational

         

LOOP ID - 2120C

 

 

1

 

 

 

 

 

 

 

 

340

NM1

Subscriber Benefit Related Entity Name

O

1

 

 

Situational

         

 

360

N3

Subscriber Benefit Related Entity Address

O

1

 

 

Situational

         

 

370

N4

Subscriber Benefit Related City/State/ZIP Code

O

1

 

 

Situational

         

 

380

PER

Subscriber Benefit Related Entity Contact Information

O

3

 

 

Situational

         

 

390

PRV

Subscriber Benefit Related Provider Information

O

1

 

 

Situational

         

 

400

LE

Loop Trailer

M

1

 

 

Situational

         

LOOP ID - 2000D

 

 

>1

 

 

 

 

 

 

 

 

010

HL

Dependent Level

O

1

 

 

Situational

         

 

020

TRN

Dependent Trace Number

O

3

 

N2/020

Situational

         

LOOP ID - 2100D

 

 

1

 

 

 

 

 

 

 

 

030

NM1

Dependent Name

O

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

         

 

080

PER

Dependent Contact Information

O

3

 

 

Situational

         

 

085

AAA

Dependent Request Validation

O

9

 

 

Situational

         

 

100

DMG

Dependent Demographic Information

O

1

 

 

Situational

         

 

110

INS

Dependent Relationship

O

1

 

 

Situational

         

 

120

DTP

Dependent Date

O

9

 

 

Situational

         

LOOP ID - 2110D

 

 

>1

 

 

 

 

 

 

 

 

130

EB

Dependent Eligibility or Benefit Information

O

1

 

 

Situational

         

 

135

HSD

Health Care Services Delivery

O

9

 

 

Situational

         

 

140

REF

Dependent Additional Identification

O

9

 

 

Situational

         

 

150

DTP

Dependent Eligibility/Benefit Date

O

20

 

 

Situational

         

 

160

AAA

Dependent Request Validation

O

9

 

 

Situational

         

 

250

MSG

Message Text

O

10

 

 

Not recommended

         

LOOP ID - 2115D

 

 

10

 

 

 

 

 

 

 

 

260

III

Dependent Eligibility or Benefit Additional Information

O

1

 

 

Situational

         

LOOP ID - LS

 

 

1

 

 

 

 

 

 

 

 

330

LS

Dependent Eligibility or Benefit Information

O

1

 

 

Situational

         

LOOP ID - 2120D

 

 

1

 

 

 

 

 

 

 

 

340

NM1

Dependent Benefit Related Entity Name

O

1

 

 

Situational

         

 

360

N3

Dependent Benefit Related Entity Address

O

1

 

 

Situational

         

 

370

N4

Dependent Benefit Related Entity City/State/ZIP Code

O

1

 

 

Situational

         

 

380

PER

Dependent Benefit Related Entity Contact Information

O

3

 

 

Situational

         

 

390

PRV

Dependent Benefit Related Provider Information

O

1

 

 

Situational

         

 

400

LE

Loop Trailer

M

1

 

 

Situational

         

 

410

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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