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Revision Date: January 2011 Version: 3.0 Page 1-2
Table of Contents
Section 1: Revision History ................................................................................... 1-4
Section 2: Introduction .......................................................................................... 2-5 Overview – ASC X12N 270 (005010X279A1) – Eligibility Request
Transaction Specifications................................................................................... 2-5
Section 3: Eligibility Request Transaction Specifications .................................. 3-6 Segment Usage – 270 .......................................................................................... 3-6 Segment and Data Element Description .............................................................. 3-8
Header ............................................................................................................. 3-9 ST - Transaction Set Header ....................................................................... 3-9 BHT - Beginning of Hierarchical Transaction ............................................ 3-9
INFORMATION SOURCE LEVEL .............................................................. 3-9 HL - Utilization Management Organization (UMO) Level ........................ 3-9 NM1 - INFORMATION SOURCE NAME ............................................... 3-9
INFORMATION RECIEVER DETAIL LEVEL ......................................... 3-10 HL - Information Receiver Level ............................................................. 3-10 NM1 - Information Receiver Name .......................................................... 3-10 REF - Information Receiver Additional Identification ............................. 3-11 N3 - Information Receiver Address .......................................................... 3-11 N4 - Information Receiver City, State, Zip Code ..................................... 3-11 PRV - Information Receiver Provider Information .................................. 3-11
SUBSCRIBER DETAIL LEVEL ................................................................. 3-12 HL - Subscriber Level .............................................................................. 3-12 TRN - Subscriber Trace Number .............................................................. 3-12 NM1 - Subscriber Name ........................................................................... 3-12 REF - Subscriber Additional Identification .............................................. 3-13 N3 - Subscriber Address ........................................................................... 3-13 N4 - Subscriber Receiver City, State, Zip Code ....................................... 3-13 PRV - Information .................................................................................... 3-13 DMG - Subscriber Demographic Information .......................................... 3-14 INS - Multiple Birth Sequence Number ................................................... 3-14 HI - Subscriber Health Care Diagnosis Code ........................................... 3-14 DTP - Subscriber Date .............................................................................. 3-14
SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY LEVEL ............... 3-14 EQ - Subscriber Eligibility or Benefit Inquiry .......................................... 3-14 AMT - Subscriber Spend Down Amount ................................................. 3-15 III - Subscriber Eligibility Or Benefit Additional Inquiry
Information ............................................................................................... 3-15 REF - Subscriber Additional Information................................................. 3-15 DTP - Subscriber Eligibility/Benefit Date ................................................ 3-15
Transaction Set Trailer .................................................................................. 3-15 SE - Transaction Set Trailer ..................................................................... 3-15
Section 4: Eligibility Benefit Response Transaction Specifications ................. 4-16 Segment Usage – 271 .................................................................................... 4-16 Header ........................................................................................................... 4-19
ST - Transaction Set Header ..................................................................... 4-19 BHT - Beginning of Hierarchical Transaction .......................................... 4-19
INFORMATION SOURCE LEVEL ............................................................ 4-19 HL - Information Source Level ................................................................ 4-19
Revision Date: January 2011
Version: 3.0 Page 1-3
AAA - Request Validation ........................................................................ 4-19 NM1 - INFORMATION SOURCE NAME ............................................. 4-20 PER - Information Source Contact Information ....................................... 4-20 AAA - Request Validation ........................................................................ 4-21
INFORMATION RECIEVER DETAIL LEVEL ......................................... 4-21 HL - Information Receiver Level ............................................................. 4-21 NM1 - Information Receiver Name .......................................................... 4-21 REF - Information Receiver Additional Identification ............................. 4-21 N3 – Information Receiver Address ......................................................... 4-22 N4 - Information Receiver City, State, Zip Code ..................................... 4-22 AAA - Information Receiver Request Validation..................................... 4-22 PRV - Information Receiver Provider Information .................................. 4-22
SUBSCRIBER DETAIL LEVEL ................................................................. 4-23 HL - Subscriber Level .............................................................................. 4-23 TRN - Subscriber Trace Number .............................................................. 4-23 NM1 - Subscriber Name ........................................................................... 4-23 REF - Subscriber Additional Identification .............................................. 4-23 N3 - Subscriber Address ........................................................................... 4-24 N4 - Subscriber Receiver City, State, Zip Code ....................................... 4-24 AAA - Subscriber Request Validation ...................................................... 4-24 PRV - Provider Information ..................................................................... 4-24 DMG - Subscriber Demographic Information .......................................... 4-24 INS - Subscriber Relationship .................................................................. 4-25 HI - Subscriber Health Care Diagnosis Code ........................................... 4-25 DTP - Subscriber Date .............................................................................. 4-25 EB - Subscriber Eligibility Or Benefit Information .................................. 4-25 HSD - Health Care Services Delivery ...................................................... 4-25 REF - Subscriber Additional Information................................................. 4-26 DTP - Subscriber Eligibility/Benefit Date ................................................ 4-26 AAA - Subscriber Request Validation ...................................................... 4-26 MSG - Message Text ................................................................................ 4-26 III - Subscriber Eligibility or Benefit Additional Information .................. 4-26 LS - Loop Header ..................................................................................... 4-27 NM1 - Subscriber Benefit Related Entity Name ...................................... 4-27 N3 - Subscriber Benefit Related Entity Address ...................................... 4-27 N4 - Subscriber Benefit Related Entity City, State, Zip Code .................. 4-27 PER - Subscriber Benefit Related Entity Contact Information ................. 4-27 PRV - Subscriber Benefit Related Provider Information .......................... 4-28 LE - Loop Trailer ...................................................................................... 4-28
Transaction Set Trailer .................................................................................. 4-28 SE - Transaction Set Trailer ..................................................................... 4-28
Revision Date: January 2011
Version: 3.0 Page 1-4
Section 1: Revision History
Document
Version
Number
Revision Date Revision
Page
Number(s)
Reason for Revisions Revisions Completed
By
Version 1.0 September 2003 All New document ISDH HIPAA EDI Team
Version 2.0 May 2008 NPI update ISDH HIPAA / EDI
Version 2.3 October 2008 All Overall update ISDH HIPAA / EDI
Version 3.0 January 2011 All 5010 Update
005010X279A1
ISDH HIPAA / EDI
Revision Date: January 2011 Version: 3.0 Page 2-5
Section 2: Introduction
Overview – ASC X12N 270 (005010X279A1) – Eligibility Request Transaction Specifications
The ASC X12N 270 (005010X279A1) transaction is the HIPAA-mandated method
for submitting an eligibility request. The transaction may be designed to request
general ISDH program eligibility information or program benefit limitations. ISDH
will accept an unlimited number of 270 requests per day, however, we will be
processing requests in batch mode once per 24 hour period given system availability.
This section is intended only as a companion guide and is not intended to contradict
or replace any information in the IG.
It is highly recommended that implementers have the following resources available
during the development process:
• This document - the Companion Guide – 270/271 Eligibility Transaction
• ASC X12N 270 – 271: 005010X279 Implementation Guide
• ASC X12N 270 – 271: 005010X279A1 Implementation Guide Addenda
Companion Guide – 270/271 Eligibility Transaction
Revision Date: January 2011
Version: 3.0 Page 3-6
Section 3: Eligibility Request Transaction Specifications
Segment Usage – 270
The following matrix lists all segments available for submission with the 5010
version of the 270 IG. Additionally, it includes a Usage column identifying segments
that are required, situational, or not used by the ISDH.
A required segment element must appear on all transactions.
Failure to include a required segment results in a compliance error.
A situational segment is not required on every type of transaction; however, a
situational segment may be required under certain circumstances.
Any data in a segment identified in the Usage column with an X is ignored by the
ISDH.
Any segment identified in the Usage column as required, or situational, is explained
in detail in this section.
Any element identified as, Not Used by ISDH, is not required for processing by
ISDH.
Table 3.1 – Segment Usage – 270
Segment ID Loop ID Segment Name ISDH Usage
R – Required
S – Situational
X – Not Used
ST N/A Transaction Set Header R
BHT N/A Beginning of Hierarchical Transaction R
HL 2000A Information Source Level R
NM1 2100A Information Source Name R
HL 2000B Information Receiver Level R
NM1 2100B Information Receiver Name R
REF 2100B Information Receiver Additional Identification S
N3 2100B Information Receiver Address S
N4 2100B Information Receiver City, State, Zip Code S
PRV 2100B Information Receiver Provider Information S
HL 2000C Subscriber Level R
TRN 2000C Subscriber Trace Number S
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Revision Date: January 2011
Version: 3.0 Page 3-7
Table 3.1 – Segment Usage – 270
Segment ID Loop ID Segment Name ISDH Usage
R – Required
S – Situational
X – Not Used
NM1 2100C Subscriber Name R
REF 2100C Subscriber Additional Identification S
N3 2100C Subscriber Address S
N4 2100C Subscriber City/State/ZIP Code S
PRV 2100C Provider Information S
DMG 2100C Subscriber Demographic Information S
INS 2100C Multiple Birth Sequence Number S
HI 2100C Subscriber Health Care Diagnosis Code S
DTP 2100C SUBSCRIBER DATE S
EQ 2110C SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY
S
AMT 2110C SUBSCRIBER SPEND DOWN AMOUNT X
AMT 2110C SUBSCRIBER SPEND DOWN TOTAL BILLED AMOUNT
X
III 2110C SUBSCRIBER ELIGIBILITY OR BENEFIT
ADDITIONAL INQUIRY INFORMATION S
REF 2110C SUBSCRIBER ADDITIONAL INFORMATION S
DTP 2110C SUBSCRIBER ELIGIBILITY/BENEFIT DATE S
HL 2000D Dependent Level X
TRN 2000D Dependent Trace Number X
NM1 2100D Dependent Name X
REF 2100D Dependent Additional Identification X
N3 2100D Dependent Address X
N4 2100D Dependent City/State/ZIP Code X
PRV 2100D Provider Information X
DMG 2100D Dependent Demographic Information X
INS 2100D Dependent Relationship X
HI 2100D Dependent Health Care Diagnosis Code X
DTP 2100D Dependent Date X
EQ 2110D Dependent Eligibility Or Benefit Inquiry X
III 2110D Dependent Eligibility Or Benefit Additional Inquiry Information
X
REF 2110D Dependent Additional Information X
DTP 2110D Dependent Eligibility/Benefit Date X
Companion Guide – 270/271 Eligibility Transaction
Revision Date: January 2011
Version: 3.0 Page 3-8
Table 3.1 – Segment Usage – 270
Segment ID Loop ID Segment Name ISDH Usage
R – Required
S – Situational
X – Not Used
SE N/A Transaction Set Trailer R
Segment and Data Element Description
This section contains a tabular representation of any segment required or situational for the ISDH HIPAA implementation of the 837I. Each segment table contains rows and columns describing different segment elements.
Segment Name – The industry assigned segment name as identified in the IG.
Segment ID – The industry assigned segment ID as identified in the IG.
Loop ID – The loop within which the segment should appear.
Usage – Identifies the segment as required or situational.
Segment Notes – A brief description of the purpose or use of the segment.
Example – An example of complete segment.
Element ID – The industry assigned data element ID as identified in the IG.
Usage – Identifies the data element as R-required, S-situational, or N/A-not used.
Guide Description/Valid Values – Industry name associated with the data element. If no industry name exists, this is the IG data element name. This column also lists in BOLD the values and/or code set to be used.
Comments – Description of the contents of the data elements including field lengths.
Companion Guide – 270/271 Eligibility Transaction
Revision Date: January 2011
Version: 3.0 Page 3-9
Header
Segment Name ST - Transaction Set Header
Segment ID ST
Loop ID N/A
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
Segment Name BHT - Beginning of Hierarchical Transaction
Segment ID BHT
Loop ID N/A
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
INFORMATION SOURCE LEVEL
Segment Name HL - Utilization Management Organization (UMO) Level
Segment ID HL
Loop ID 2000A
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
Segment Name NM1 - INFORMATION SOURCE NAME
Segment ID NM1
Loop ID 2100A
Usage Required
Segment Notes
See ISDH specific rules below.
Element ID Usage Guide Description/Valid Values Comments
NM101 R Entity Identifier Code
PR - Payer Organization
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Revision Date: January 2011
Version: 3.0 Page 3-10
NM102 R Entity Type Qualifier
2 – Non-Person Entity
NM103 S Utilization Management Organization (UMO) Last or Organization Name
CSHCS
NM104 S Subscriber’s First Name
NM105 S Subscriber’s Middle Initial
NM106 N/A Name Prefix Not used per IG
NM107 S Subscriber Name Suffix
NM108 R Identification Code Qualifier
24 – Employer’s Identification Number
NM109 R Utilization Management Organization (UMO) Identifier
NM110 N/A Entity Relationship Code Not used per IG
NM111 N/A Entity Identifier Code Not used per IG
NM112 N/A Name Last or Organization Name Not used per IG
INFORMATION RECIEVER DETAIL LEVEL
Segment Name HL - Information Receiver Level
Segment ID HL
Loop ID 2000B
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
Segment Name NM1 - Information Receiver Name
Segment ID NM1
Loop ID 2100B
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
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Revision Date: January 2011
Version: 3.0 Page 3-11
Segment Name REF - Information Receiver Additional Identification
Segment ID REF
Loop ID 2100B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name N3 - Information Receiver Address
Segment ID N3
Loop ID 2100B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name N4 - Information Receiver City, State, Zip Code
Segment ID N3
Loop ID 2100B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name PRV - Information Receiver Provider Information
Segment ID PRV
Loop ID 2100B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
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Revision Date: January 2011
Version: 3.0 Page 3-12
SUBSCRIBER DETAIL LEVEL
Segment Name HL - Subscriber Level
Segment ID HL
Loop ID 2000B
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
Segment Name TRN - Subscriber Trace Number
Segment ID TRN
Loop ID 2000C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name NM1 - Subscriber Name
Segment ID NM1
Loop ID 2100C
Usage Required
Segment Notes
See ISDH specific rules below. All patients are subscribers.
Element ID Usage Guide Description/Valid Values Comments
NM101 R Entity Identifier Code
IL - Insured or Subscriber
NM102 R Entity Type Qualifier
1 - Person
NM103 S Subscriber Last Name ISDH CSHCS: Scriber is the patient; per IG this field is required.
NM104 S Subscriber’s First Name ISDH CSHCS: Scriber is the patient
NM105 S Subscriber’s Middle Initial
NM106 N/A Name Prefix Not used per IG
NM107 S Subscriber Name Suffix
NM108 S Identification Code Qualifier
MI - Member Identification Number
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Element ID Usage Guide Description/Valid Values Comments
NM109 S Identification Code CSHCS 6-digit Participant ID
NM110 N/A Entity Relationship Code Not used per IG
NM111 N/A Entity Identifier Code Not used per IG
NM112 N/A Name Last or Organization Name Not used per IG
Segment Name REF - Subscriber Additional Identification
Segment ID REF
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name N3 - Subscriber Address
Segment ID N3
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name N4 - Subscriber Receiver City, State, Zip Code
Segment ID N3
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name PRV - Information
Segment ID PRV
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
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Revision Date: January 2011
Version: 3.0 Page 3-14
Segment Name DMG - Subscriber Demographic Information
Segment ID REF
Loop ID 2000C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name INS - Multiple Birth Sequence Number
Segment ID INS
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name HI - Subscriber Health Care Diagnosis Code
Segment ID HI
Loop ID 2100C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
Segment Name DTP - Subscriber Date
Segment ID DTP
Loop ID 2100C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY LEVEL
Segment Name EQ - Subscriber Eligibility or Benefit Inquiry
Segment ID EQ
Loop ID 2110C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
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Revision Date: January 2011
Version: 3.0 Page 3-15
Segment Name AMT - Subscriber Spend Down Amount
Segment ID AMT
Loop ID 2110C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
Segment Name III - Subscriber Eligibility Or Benefit Additional Inquiry
Information Segment ID III
Loop ID 2110C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
Segment Name REF - Subscriber Additional Information
Segment ID III
Loop ID 2110C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
Segment Name DTP - Subscriber Eligibility/Benefit Date
Segment ID DTP
Loop ID 2110C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
Transaction Set Trailer
Segment Name SE - Transaction Set Trailer
Segment ID SE
Loop ID N/A
Usage Required
Segment Notes Follow the HIPAA and A1 IG rules.
Companion Guide – 270 Eligibility Transaction
Revision Date: January 2011
Version: 3.0 Page 4-16
Section 4: Eligibility Benefit Response Transaction Specifications
Segment Usage – 271
The following matrix lists all segments available for submission with the 5010
version of the 270 IG. Additionally, it includes a Usage column identifying segments
that are required, situational, or not used by the ISDH.
A required segment element must appear on all transactions.
Failure to include a required segment results in a compliance error.
A situational segment is not required on every type of transaction; however, a
situational segment may be required under certain circumstances.
Any data in a segment identified in the Usage column with an X is ignored by the
ISDH.
Any segment identified in the Usage column as required, or situational, is explained
in detail in this section.
Any element identified as, Not Used by ISDH, is not required for processing by
ISDH.
Table 3.1 – Segment Usage – 271
Segment ID Loop ID Segment Name ISDH Usage
R – Required
S – Situational
X – Not Used
ST N/A Transaction Set Header R
BHT N/A Beginning of Hierarchical Transaction R
HL 2000A Information Source Level R
AAA 2000A Request Validation S
NM1 2100A Information Source Name R
PER 2100A Information Source Contact Information S
AAA 2100A Request Validation S
HL 2000B Information Receiver Level S
NM1 2100B Information Receiver Name R
REF 2100B Information Receiver Additional Identification S
N3 2100B Information Receiver Address S
N4 2100B Information Receiver City, State, Zip Code S
AAA 2100B Information Receiver Request Validation S
Companion Guide – 270 Eligibility Transaction
Revision Date: January 2011
Version: 3.0 Page 4-17
Table 3.1 – Segment Usage – 271
Segment ID Loop ID Segment Name ISDH Usage
R – Required
S – Situational
X – Not Used
PRV 2100B Information Receiver Provider Information S
HL 2000C Subscriber Level S
TRN 2000C Subscriber Trace Number S
NM1 2100C Subscriber Name R
REF 2100C Subscriber Additional Identification S
N3 2100C Subscriber Address S
N4 2100C Subscriber City/State/ZIP Code S
AAA 2100C Subscriber Request Validation S
PRV 2100C Provider Information S
DMG 2100C Subscriber Demographic Information S
INS 2100C Subscriber Relationship S
HI 2100C Subscriber Health Care Diagnosis Code S
DTP 2100C Subscriber Date S
MPI 2100C Subscriber Military Personnel Information X
EB 2110C Subscriber Eligibility Or Benefit Information S
HSD 2110C Health Care Services Delivery S
REF 2110C Subscriber Additional Identification S
DTP 2110C Subscriber Eligibility/Benefit Date S
AAA 2110C Subscriber Request Validation S
MSG 2110C Message Text S
III 2115C Subscriber Eligibility or Benefit Additional Information
S
LS 2110C Loop Header S
NM1 2120C Subscriber Benefit Related Entity Name S
N3 2120C Subscriber Benefit Related Entity Address S
N4 2120C Subscriber Benefit Related Entity City, State, Zip Code
S
PER 2120C Subscriber Benefit Related Entity Contact Information
S
PRV 2120C Subscriber Benefit Related Provider Information
S
LE 2110C Loop Trailer S
HL 2000D Dependent Level X
TRN 2000D Dependent Trace Number X
Companion Guide – 270 Eligibility Transaction
Revision Date: January 2011
Version: 3.0 Page 4-18
Table 3.1 – Segment Usage – 271
Segment ID Loop ID Segment Name ISDH Usage
R – Required
S – Situational
X – Not Used
NM1 2100D Dependent Name X
REF 2100D Dependent Additional Identification X
N3 2100D Dependent Address X
N4 2100D Dependent City/State/ZIP Code X
AAA 2100D Dependent Request Validation X
PRV 2100D Provider Information X
DMG 2100D Dependent Demographic Information X
INS 2100D Dependent Relationship X
HI 2100D Dependent Health Care Diagnosis Code X
DTP 2100D Dependent Date X
MPI 2100D Dependent Military Personal Information X
EB 2110D Dependent Eligibility Or Benefit Information
X
HSD 2110D Health Care Services Delivery X
REF 2110D Dependent Additional Identification X
DTP 2110D Dependent Eligibility/Benefit Date X
AAA 2100D Dependent Request Validation X
MSG 2100D Message Text X
III 2115D Dependent Eligibility or Benefit Additional Information
X
LS 2110D Loop Header X
NM1 2120D Dependent Benefit Related Entity Name X
N3 2120D Dependent Benefit Related Entity Address X
N4 2120D Dependent Benefit Related Entity City, State, Zip Code
X
PER 2120D Dependent Benefit Related Entity Contact Information
X
PRV 2120D Dependent Benefit Related Provider Information
X
LE 2110C Loop Trailer X
SE Transaction Set Trailer R
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Revision Date: January 2011 Version: 3.0 Page 4-19
Header
Segment Name ST - Transaction Set Header
Segment ID ST
Loop ID N/A
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
Segment Name BHT - Beginning of Hierarchical Transaction
Segment ID BHT
Loop ID N/A
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
INFORMATION SOURCE LEVEL
Segment Name HL - Information Source Level
Segment ID HL
Loop ID 2000A
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
Segment Name AAA - Request Validation
Segment ID AAA
Loop ID 2000A
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Companion Guide – 270 Eligibility Transaction
Revision Date: January 2011
Version: 3.0 Page 4-20
Segment Name NM1 - INFORMATION SOURCE NAME
Segment ID NM1
Loop ID 2100A
Usage Required
Segment Notes
See ISDH specific rules below.
Element ID Usage Guide Description/Valid Values Comments
NM101 R Entity Identifier Code
PR - Payer Organization
NM102 R Entity Type Qualifier
2 – Non-Person Entity
NM103 S Utilization Management Organization (UMO) Last or Organization Name
CSHCS
NM104 S Subscriber’s First Name
NM105 S Subscriber’s Middle Initial
NM106 N/A Name Prefix Not used per IG
NM107 S Subscriber Name Suffix
NM108 R Identification Code Qualifier
24 – Employer’s Identification Number
NM109 R Utilization Management Organization (UMO) Identifier
NM110 N/A Entity Relationship Code Not used per IG
NM111 N/A Entity Identifier Code Not used per IG
NM112 N/A Name Last or Organization Name Not used per IG
Segment Name PER - Information Source Contact Information
Segment ID PER
Loop ID 2100A
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
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Revision Date: January 2011
Version: 3.0 Page 4-21
Segment Name AAA - Request Validation
Segment ID AAA
Loop ID 2100A
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
INFORMATION RECIEVER DETAIL LEVEL
Segment Name HL - Information Receiver Level
Segment ID HL
Loop ID 2000B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name NM1 - Information Receiver Name
Segment ID NM1
Loop ID 2100B
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
Segment Name REF - Information Receiver Additional Identification
Segment ID REF
Loop ID 2100B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Companion Guide – 270 Eligibility Transaction
Revision Date: January 2011
Version: 3.0 Page 4-22
Segment Name N3 – Information Receiver Address
Segment ID N3
Loop ID 2100B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name N4 - Information Receiver City, State, Zip Code
Segment ID N4
Loop ID 2100B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name AAA - Information Receiver Request Validation
Segment ID AAA
Loop ID 2100B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name PRV - Information Receiver Provider Information
Segment ID PRV
Loop ID 2100B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
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Revision Date: January 2011
Version: 3.0 Page 4-23
SUBSCRIBER DETAIL LEVEL
Segment Name HL - Subscriber Level
Segment ID HL
Loop ID 2000B
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name TRN - Subscriber Trace Number
Segment ID TRN
Loop ID 2000C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name NM1 - Subscriber Name
Segment ID NM1
Loop ID 2100C
Usage Required
Segment Notes
Follow the HIPAA and IG rules.
Segment Name REF - Subscriber Additional Identification
Segment ID REF
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
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Revision Date: January 2011
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Segment Name N3 - Subscriber Address
Segment ID N3
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name N4 - Subscriber Receiver City, State, Zip Code
Segment ID N4
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name AAA - Subscriber Request Validation
Segment ID AAA
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name PRV - Provider Information
Segment ID PRV
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name DMG - Subscriber Demographic Information
Segment ID REF
Loop ID 2000C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
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Revision Date: January 2011
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Segment Name INS - Subscriber Relationship
Segment ID INS
Loop ID 2100C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name HI - Subscriber Health Care Diagnosis Code
Segment ID HI
Loop ID 2100C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
Segment Name DTP - Subscriber Date
Segment ID DTP
Loop ID 2100C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
Segment Name EB - Subscriber Eligibility Or Benefit Information
Segment ID EB
Loop ID 2110C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
Segment Name HSD - Health Care Services Delivery
Segment ID HSD
Loop ID 2110C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
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Revision Date: January 2011
Version: 3.0 Page 4-26
Segment Name REF - Subscriber Additional Information
Segment ID III
Loop ID 2110C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
Segment Name DTP - Subscriber Eligibility/Benefit Date
Segment ID DTP
Loop ID 2110C
Usage Situational
Segment Notes Follow the HIPAA and IG rules.
Segment Name AAA - Subscriber Request Validation
Segment ID AAA
Loop ID 2110C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name MSG - Message Text
Segment ID AAA
Loop ID 2110C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name III - Subscriber Eligibility or Benefit Additional Information
Segment ID III
Loop ID 2115C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Companion Guide – 270 Eligibility Transaction
Revision Date: January 2011
Version: 3.0 Page 4-27
Segment Name LS - Loop Header
Segment ID LS
Loop ID 2110C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name NM1 - Subscriber Benefit Related Entity Name
Segment ID NM1
Loop ID 2120C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name N3 - Subscriber Benefit Related Entity Address
Segment ID N3
Loop ID 2120C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name N4 - Subscriber Benefit Related Entity City, State, Zip Code
Segment ID N4
Loop ID 2120C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name PER - Subscriber Benefit Related Entity Contact Information
Segment ID PER
Loop ID 2120C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Companion Guide – 270 Eligibility Transaction
Revision Date: January 2011
Version: 3.0 Page 4-28
Segment Name PRV - Subscriber Benefit Related Provider Information
Segment ID PRV
Loop ID 2120C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Segment Name LE - Loop Trailer
Segment ID LE
Loop ID 2110C
Usage Situational
Segment Notes
Follow the HIPAA and IG rules.
Transaction Set Trailer
Segment Name SE - Transaction Set Trailer
Segment ID SE
Loop ID N/A
Usage Required
Segment Notes
Follow the HIPAA and A1 IG rules.
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