Subscriber Eligibility or Benefit Information

Pos: 130

Max: 1

Detail - Optional

Loop: 2110C

Elements: 13

User Option (Usage): Situational

To supply eligibility or benefit information

Element Summary:

	Ref	Id	Element Name	Req	Type	Min/Max	Usage
	EB01	1390	Eligibility or Benefit Information Description: Code identifying eligibility or benefit information Use this code to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category that is being further described in the following data elements. This data element also qualifies the data in elements EB06 through EB10.	M	ID	1/2	Required

Code

Name

Active Coverage

Active - Full Risk Capitation

Active - Services Capitated

Active - Services Capitated to Primary Care Physician

Active - Pending Investigation

Inactive

Inactive - Pending Eligibility Update

Inactive - Pending Investigation

Co-Insurance

Co-Payment

Deductible

Benefit Description

Exclusions

Limitations

Out of Pocket (Stop Loss)

Unlimited

Non-Covered

Cost Containment

Reserve

Primary Care Provider

Pre-existing Condition

Services Restricted to Following Provider

Not Deemed a Medical Necessity

Benefit Disclaimer

Not recommended. See section 1.3.10 Disclaimers Within the Transaction.

Second Surgical Opinion Required

Other or Additional Payor

Prior Year(s) History

Card(s) Reported Lost/Stolen

Contact Following Entity for Eligibility or Benefit Information

Cannot Process

Other Source of Data

Health Care Facility

Spend Down

Coverage Basis

Managed Care Coordinator

EB02

1207

Coverage Level Code
Description: Code indicating the level of coverage being provided for this insured
Industry: Benefit Coverage Level Code
Use this code to identify the level of coverage of benefits. It identifies the types and number of entities that are covered by the insurance plan.
Use if available.

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

EB03

1365

Service Type Code
Description: Code identifying the classification of service
If a service type code is sent by an information receiver that is not supported by the information source, the information source must respond with at least a service type code of 30 - Health Benefit Plan Coverage. See EB segment notes and section 1.3.7 HIPAA Compliant Use of the 270/271 Transaction Set for additional information. Information receivers need to be made aware that receipt of a 271 response with a Service Type Code of 30 indicates that the information source may not be able to process an explicit request and the response does not indicate coverage of a specific benefit if one was sent in the 270 request.
If a very specific type or category of service for which eligibility or benefits can be described, use one of the codes from the full list.

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

Use this code if only a single category of benefits can be supported.

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

EB04	1336	Insurance Type Code Description: Code identifying the type of insurance policy within a specific insurance program Use if available. All valid standard codes are used.	O	ID	1/3	Situational
EB05	1204	Plan Coverage Description Description: A description or number that identifies the plan or coverage Use this free-form text area to convey the specific product name for an insurance plan. Use if available.	O	AN	1/50	Situational
EB06	615	Time Period Qualifier Description: Code defining periods Use this code for the time period category for the benefits being described when needed to qualify benefit availability.	O	ID	1/2	Situational

	Code	Name
	6	Hour
	7	Day
	13	24 Hours
	21	Years
	22	Service Year
	23	Calendar Year
	24	Year to Date
	25	Contract
	26	Episode
	27	Visit
	28	Outlier
	29	Remaining
	30	Exceeded
	31	Not Exceeded
	32	Lifetime
	33	Lifetime Remaining
	34	Month
	35	Week
	36	Admission

EB07	782	Monetary Amount Description: Monetary amount Industry: Benefit Amount Use this monetary amount as qualified by EB01. Use if eligibility or benefit must be qualified by a monetary amount; e.g., deductible, co-payment.	O	R	1/18	Situational
EB08	954	Percent Description: Percentage expressed as a decimal Industry: Benefit Percent Use this percentage rate as qualified by EB01. Use if eligibility or benefit must be qualified by a percentage; e.g., co-insurance.	O	R	1/10	Situational
EB09	673	Quantity Qualifier Description: Code specifying the type of quantity Use this code to identify the type of units that are being conveyed in the following data element (EB10).	C	ID	2/2	Situational

Code

Name

Quantity Used

Covered - Actual

Covered - Estimated

Deductible Blood Units

Days

Hours

Life-time Reserve - Actual

Life-time Reserve - Estimated

Month

Number of Services or Procedures

Quantity Approved

Age, High Value

Use this code when a benefit is based on a maximum age for the patient.

Age, Low Value

Use this code when a benefit is based on a minimum age for the patient.

Visits

Years

	EB10	380	Quantity Description: Numeric value of quantity Industry: Benefit Quantity Use this number for the quantity value as qualified by the preceding data element (EB09).	C	R	1/15	Situational
	EB11	1073	Yes/No Condition or Response Code Description: Code indicating a Yes or No condition or response Industry: Authorization or Certification Indicator Use if it is necessary to indicate if authorization or certification is required.	O	ID	1/1	Situational

	Code	Name
	N	No
	U	Unknown
	Y	Yes

EB12

1073

Yes/No Condition or Response Code
Description: Code indicating a Yes or No condition or response
Industry: In Plan Network Indicator
Use if it is necessary to indicate if benefits are considered In or Out of Plan-Network or not.

1/1

Situational

	Code	Name
	N	No
	U	Unknown
	Y	Yes

	EB13	C003	Composite Medical Procedure Identifier Description: To identify a medical procedure by its standardized codes and applicable modifiers Use this composite data element only if an information source can support this high level of functionality. The EB13 allows for a very specific response to a very specific inquiry, such as based on a diagnosis or a procedure code. This element is only recommended when responding to an inquiry that contained related EQ02 data.	O	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 identify the external code list of the following procedure/service code.	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

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.

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 ID number for the product/service code as qualified by the preceding data element.

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 Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.	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 Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.	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 Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.	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 Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.	O	AN	2/2	Situational

1.	P0910 - If either EB09,EB10 is present, then all are required

1.	EB01 qualifies EB06 through EB10.
2.	EB11 is the authorization or certification indicator. A "Y" value indicates that an authorization or certification is required per plan provisions. An "N" value indicates that an authorization or certification is not required per plan provisions. A "U" value indicates it is unknown whether the plan provisions require an authorization or certification.
3.	EB12 is the plan network indicator. A "Y" value indicates the benefits identified are considered In-Plan-Network. An "N" value indicates that the benefits identified are considered Out-Of-Plan-Network. A "U" value indicates it is unknown whether the benefits identified are part of the Plan Network.

Notes:

1. Use this segment to begin the eligibility/benefit information looping structure. The EB segment is used to convey the specific eligibility or benefit information for the entity identified.
2. This segment is required if the subscriber is the person whose eligibility or benefits are being described and the transaction is not rejected (see Section 1.3.9) or if the transaction needs to be rejected in this loop.
3. When the subscriber is not the person whose eligibility or benefits are being described, this loop must not be used.
4. A limit to the number of repeats of EB loops has not been established. In a batch environment there is no practical reason to limit the number of EB loop repeats. In a real time environment, consideration should be given to how many EB loops are generated given the amount of time it takes to format the response and the amount of time it will take to transmit that response. Since these limitations will vary by information source, it would be completely arbitrary for the developers to set a limit. It is not the intent of the developers to limit the amount of information that is returned in a response, rather to alert information sources to consider the potential delays if the response contains too much information to be formatted and transmitted in real time.
5. The minimum data for a HIPAA compliant response for a person that has been located in the information source�s system must indicate either, 1- Active Coverage or 6 - Inactive in EB01 and, 30 - Health Benefit Plan Coverage in EB03. Information sources are not limited to the minimum HIPAA compliant response and are highly encouraged to create as elaborate a response their systems allow. See section 1.3.7 HIPAA Compliant Use of the 270/271 Transaction Set for additional information.

Example:

EB*1*FAM*96*GP~
EB*B**98***27*10**VS*1~
EB*C*IND****23*200~
EB*C*FAM****23*600~
EB*A**A6*****.50~