III

Dependent Eligibility or Benefit Additional Information

Pos: 260

Max: 1

Detail - Optional

Loop: 2115D

Elements: 2

	Ref	Id	Element Name	Req	Type	Min/Max	Usage
	III01	1270	Code List Qualifier Code Description: Code identifying a specific industry code list Use this code to specify if the code that is following in the III02 is a Principal Diagnosis Code, a Diagnosis Code or a Facility Type Code.	C	ID	1/3	Required

Code

Name

Diagnosis

CODE SOURCE:

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

Principal Diagnosis

CODE SOURCE:

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

Mutually Defined

Use this code for Facility Type Code. See Appendix C for Code Source 237, Place of Service from Health Care Financing Administration Claim Form.

III02

1271

Industry Code
Description: Code indicating a code from a specific industry code list
If III01 is either BK or BF, use this element for diagnosis code from code source 131.
If III01 is ZZ, use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below, however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here.

11 Office
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility

1/30

Required

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

	ExternalCodeList
	Name: 237
	Description: Place of Service from Health Care Financing Administration Claim Form

Notes:

1. Use this segment to begin the Dependent Eligibility or Benefit Additional Information looping structure.
2. This segment has two purposes. Information that was received in III segments in Loop 2110D of the 270 Inquiry and was used in the determination of the eligibility or benefit response must be returned. If information was provided in III segments of Loop 2110D but was not used in the determination of the eligibiltiy or benefits it must not be returned. This segment can also be used to identify limitations in the benefits explained in the corresponding Loop 2110D, such as if benefits are limited to a type of facility or for a specific diagnosis code.
3. Use this segment to identify Diagnosis codes and/or Facility Type as they relate to the information provided in the EB segment.
4. Use the III segment only if an information source can support this high level functionality.
5. Use this segment only one time for the Principal Diagnosis Code and only one time for Facility Type Code.

Example:

III*BK*486~
III*ZZ*21~

1.	P0102 - If either III01,III02 is present, then all are required
2.	L030405 - If III03 is present, then at least one of III04,III05 is required