Eligibility JSON-to-EDI API Contents
Use our OpenAPI Spec JSON file as a reference for development. Notes on the data in the following sections include:
- The Constraints column describes the minimum and maximum number of alphanumeric characters that a field entry can occupy: for example, 1/60 R is a Required field with a minimum of one and maximum of 60 characters.
- If a field is required, the Constraints entry notes it.
For the Constraints column in each table, the following letters stand for specific meanings:
- R = Required (must be used if/when the object is part of the transaction);
- S = Situational (may be required depending on how the transaction content is structured).
Situational loops, segments, or elements can be Situational in two forms:
- Required
IFa condition is met, but can be used at the discretion of the sender if it is not required (for example, some descriptive notes can be added to a claim if necessary); - Required
IFa condition is met, but if not, the sender must not use it in the request ("Do not send").
NOTE
To obtain a license that also provides access to the full requirements for these transactions, visit https://x12.org/licensing. We make every effort to ensure consistency between our APIs and the X12 TR3. If there is a discrepancy, the X12 TR3 is the final authority.
Page 54 of the Consolidated 270/271 Implementation Guide discusses this in further detail.
NOTE
To obtain a license that also provides access to the full requirements for these transactions, visit https://x12.org/licensing. We make every effort to ensure consistency between our APIs and the X12 TR3. If there is a discrepancy, the X12 TR3 is the final authority.
Eligibility 270 Request
Identification Leader (Response)
Subscriber Trace Number (Response) 2000C/D
Plan Information (Response) 2100C/D
Plan Date Information (Response) 2100C/D
Plan Status (Response) 2110C/D
Eligibility Benefit Information (Response) 2110C/D
Benefit Date Information (Response) 2110C/D
Benefits Information (Response) 2110C/D
Additional Benefit Information (Response) 2110C/D
Benefits Related Entity (Response) 2120C/D
Eligibility Information (Response) 2115C/D
Contact Information (Response) 2100B, 2120C/D
Provider Information (Response) 2100B, 2110C/D
Benefits Service Delivery (Response) 2110C/D
Eligibility API JSON-to-EDI mapping
Eligibility 270 Request
Identification Header (Request)
| Field | Description | Constratints |
|---|---|---|
controlNumber | Transaction Set Control Number. This is provided by the submitter. Unique ID used to trace the request. | R 9/9 |
tradingPartnerServiceId | ID used by the clearinghouse for the trading partner. Loop 2100A, NM109. Get the serviceId through your ConnectCenter account from Payer Lists page. | R 2/80 |
submitterTransactionIdentifier | Derived from BHT03 in the BHT segment that defines the transaction set (no loop). This field is required because the 270 transaction is processed through an API. | R 1/50 |
See Page 92-93 of the 270/271 Implementation Guide for further detail.
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
subscriberTraceNumber (Object) | — | — | Identify a transaction to the payer. | S |
traceTypeCode | TRN01 | 2000C/D | Defines the referenced transaction. | 1/2 R |
traceType | TRN02 | 2000C/D | The trace number, from either the information receiver or from the clearinghouse. | 1/50 R |
referenceIdentification | TRN04 | 2000C/D | Trace number used in the 270 TRN segment, or used by payer for more-specific identification. Based on value in TRN01. | 10/10/ S |
originatingCompanyIdentifier | TR03 | 2000C/D | ID for the company that assigned the trace/reference number in the TRN02 element. | 10/10 R |
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
provider (Object) | ||||
organizationName | NM103 | 2100B | Provider’s organization name. Can use organization or last name. | 1/60 R |
firstName | NM104 | 2100B | Provider first name. | 1/35 |
lastName | NM103 | 2100B | Provider last name. Can use organization or last name. | 1/60 R |
| One of the following NM109 ID’s is required. | ||||
npi | NM109 | 2100B | National Provider Identification value. NM108=XX | 2/80 |
serviceProviderNumber | NM109 | 2100B | Service Provider number. NM108=SV | 2/80 |
payorID | NM109 | 2100B | Payor ID value. NM108=PI | 2/80 |
taxId | NM109 | 2100B | Electronic Transmitter Identification Number (ETIN) value. NM108=FI | 2/80 |
ssn | NM109 | 2100B | Social Security number. NM108=34 | 2/80 |
pharmacyProcessorNumber | NM109 | 2100B | Pharmacy processor number. NM108=PP | 2/80 |
servicesPlanID | NM109 | 2100B | See annotation in OpenAPI spec. | 2/80 |
employersId | NM109 | 2100B | See annotation in OpenAPI spec. | 2/80 |
providerCode | PRV01 | 2100B | Identifies the type of provider. Example: AD = Admitting Provider Required if Ref ID PRV03 is provided. See annotation in OpenAPI spec. | 1/3 R |
referenceIdentification | PRV03 | 2100B | Healthcare Provider Taxonomy code value. | 1/50 S |
providerType | MN101 | 2100B | Insurance provider type. See annotation in OpenAPI spec. | 1/60 S |
address (Object) | ||||
address1 | N301 | 2100C/D | Provider’s address line 1. | 1/35 R |
address2 | N302 | 2100C/D | Provider’s address line 2. | 1/35 S |
city | N401 | 2100C/D | Provider’s city. | 1/60 R |
state | N402 | 2100C/D | Provider’s state. | 1/35 S |
postalCode | N403 | 2100C/D | Provider’s postal code. | 1/1 S |
Required when the information available in Loop 2100B NM1 is not enough to fully identify the information receiver. Because this is not required in the TR3, the submitter can send this content at their discretion; it is not required by the Eligibility query recipient.
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| One of the following REF02 IDs is required. | ||||
portalUsername | REF02 | 2100B | User Identification REF01=JD. | 1/50 |
portalPassword | REF02 | 2100B | Personal Identification Number (PIN) REF01=4A. | 1/50 |
informationReceiverName (Object) | S | |||
stateLicenceNumber | REF02 | 2100B | State License Number REF01=0B. | 1/50 |
medicareProviderNumber | REF02. | 2100B | Medicare Provider Number REF01=1C | 1/50 |
medicaidProviderNumber | REF02. | 2100B | Medicaid Provider Number REF01=1D | 1/50 |
facilityIdNumber | REF02 | 2100B | Facility ID Number REF01=1J | 1/50 |
contactNumber | REF02 | 2100B | Contract Number REF01=CT | 1/50 |
devicePinNumber | REF02 | 2100B | Electronic device pin number REF01=EL | 1/50 |
submitterIdNumber | REF02 | 2100B | Submitter Identification Number REF01=EO | 1/50 |
nationalProviderIdentifier | REF02 | 2100B | Centers for Medicare and Medicaid Services National Provider Identifier. REF01=HPI | 1/50 |
providerPlanNetworkIdNumber | REF02 | 2100B | Provider Plan Network Identification Number REF01=N5 | 1/50 |
facilityNetworkIdNumber | REF02 | 2100B | Facility Network Identification Number REF01=N7 | 1/50 |
priorIdentifierNumber | REF02 | 2100B | Prior Identifier Number REF01=Q4 | 1/50 |
socialSecurityNumber | REF02 | 2100B | Social Security Number REF01=SY | 1/50 |
federalTaxpayerIdentificationNumber | REF02 | 2100B | Federal Taxpayer’s Identification Number REF01=TJ | 1/50 |
| Element RFE03 may be required if REF01=0B | ||||
informationReceiverAdditionalIdentifierState | REF03 | 2100B | Information Receiver Additional Identifier State See annotation in OpenAPI spec | 1/80 |
The subscriber for the insurance policy.
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
subscriber (Object) | ||||
memberId | NM109 | 2100C | Member ID for the subscriber. NM108=MI | 2/80 S |
firstName | NM104 | 2100C | Subscriber's first name as shown on their policy | 1/35 S |
lastName | NM103 | 2100C | Subscriber's last name as shown on their policy | 1/60 S |
suffix | NM107 | 2100C | Subscriber’s Name Suffix | 1/10 S |
| Subscriber Additional Identification | 2100C | One of the following REF02 ID’s is required. | S | |
groupNumber | REF02 | 2100C | Subscriber's group or policy number as shown on their policy. REF01=6P | 1/50 |
idCard | REF02 | 2100C | Identity Card value. REF01=HJ | 1/50 |
ssn | REF02 | 2100C | Social Security value. REF01=SY | 1/50 |
caseNumber | REF02 | 2100C | Case Number. REF01=3H | 1/50 |
medicaidRecipientIdentificationNumber | REF02 | 2100C | Medicaid Recipient Identification Number. REF01=NQ | 1/50 |
planNumber | REF02 | 2100C | Plan Number. REF01=18 | 1/50 |
policyNumber | REF02 | 2100C | Group or Policy Number. REF01=1L | 1/50 |
memberIdentificationNumber | REF02 | 2100C | Member Identification Number. REF01=1W | 1/50 |
contractNumber | REF02 | 2100C | Contract Number. REF01=CT | 1/50 |
medicalRecordIdentificationNumber | REF02 | 2100C | Medical Record Identification Number. REF01=EA | 1/50 |
medicalRecordIdentificationNumber | REF02 | 2100C | Medical Record Identification Number. REF01=EA | 1/50 |
patientAccountNumber | REF02 | 2100C | Patient Account Number. REF01=EJ | 1/50 |
healthInsuranceClaimNumber | REF02 | 2100C | Health Insurance Claim (HIC) Number. REF01=F6 | 1/50 |
identificationCardSerialNumber | REF02 | 2100C | Identification Card Serial Number. REF01=GH | 1/50 |
insurancePolicyNumber | REF02 | 2100C | Insurance Policy Number. REF01=IG | 1/50 |
planNetworkIdentificationNumber | REF02 | 2100C | Plan Network Identification Number. REF01=N6 | 1/50 |
agencyClaimNumber | REF02 | 2100C | Agency Claim Number. REF01=Y4 | 1/50 |
subscriberAddress (Object) | S | |||
address1 | N301 | 2100C | Subscriber’s address line 1 | 1/35 R |
address2 | N302 | 2100C | Subscriber’s address line 2 | 1/35 S |
city | N401 | 2100C | Subscriber’s city | 1/60 R |
state | N402 | 2100C | Subscriber’s state | 1/35 S |
postalCode | N403 | 2100C | Subscriber’s postal code | 3/15 S |
| Provider Information | ||||
providerCode | PRV01 | 2100C/D | Identifies the provider type. Example: AD=Admitting R if Ref Id PRV03 is provided. See annotation in OpenAPI spec. | 1/3 R |
referenceIdentificationQualifier | PRV02 | 2100C/D | Reference Identification Qualifier. | 2/3 S |
providerIdentifier | PRV03 | 2100C/D | Reference Identification. See annotation in OpenAPI spec. | 1/50 S |
| Subscriber Demographic Information | S | |||
dateOfBirth | DMG02 | 2100C/D | Subscriber's birth date as specified on their policy. Format: YYYYMMDD | 1/35 S |
gender | DMG03 | 2100C/D | Subscriber's gender as specified on their policy. Value: M or F | 1/1 S |
| Multiple Birth Sequence Number | S | |||
birthSequenceNumber | INS17 | 2100C | Birth Sequence Number INS01=Y INS02=18 | 1/9 R |
| Subscriber Health Care Code Information | S | |||
healthCareCodeInformation (Array of objects) | DTP03 | 2100C/D | Use to send health care codes with dates, quantities and amounts. If used, specific attributes are required. HI01 to HI08 use same segments. | R |
healthCareDiagnosisCode (Object) | S | |||
diagnosisTypeCode | HI01-1 | 2100D | Diagnosis Type Code | 1/3 R |
diagnosisCode | HI01-2 | 2100D | Diagnosis Code | 1/30 R |
| Subscriber Dates | DTP03; one date is required. | R | ||
idCardIssueDate | DTP03 | 2100C/D | ID issue date. Format: YYYYMMDD DTP01=102 DTP02=D8 | 1/35 |
beginningCardIssueDate | DTP03 | 2100C/D | Beginning Card Issue Date Format: YYYYMMDD- YYYYMMDD DTP01=102 DTP02=RD8 | 1/35 |
endCardIssueDate | DTP03 | 2100C/D | End Card Issue Date Format: YYYYMMDD- YYYYMMDD DTP01=102 DTP02=RD8 | 1/35 |
planIssueDate | DTP03 | 2100C/D | Plan issue date. Format: YYYMMDD DTP01=291 DTP02=D8 | 1/35 |
beginningPlanIssueDate | DTP03 | 2100C/D | Beginning Plan Issue Date, Format: YYYYMMDD- YYYYMMDD DTP01=291 DTP02=RD8 | 1/35 |
endPlanIssueDate | DTP03 | 2100C/D | End Plan Issue Date Format: YYYYMMDD- YYYYMMDD DTP01=291 DTP02=RD8 | 1/35 |
| Subscriber’s Military Personal Information | Use only when necessary | S | ||
informationStatusCode | MPI01 | 2000C/D 2100C/D | Information Status Code | 1/1 R |
employmentStatusCode | MPI02 | 2000C/D 2100C/D | Employment Status Code | 2/2 R |
governmentServiceAffiliationCode | MPI03 | 2000C/D 2100C/D | Government Service Affiliation Code | 1/1 R |
description | MPI04 | 2000C/D 2100C/D | Description field | 1/80 S |
militaryServiceRankCode | MPI05 | 2000C/D 2100C/D | Military Service Rank Code | 2/2 S |
dateTimeFormatQualifier | MPI06 | 2000C/D 2100C/D | Date Time Format Qualifier MPI106=D8, MPI106=RD8 | 2/3 S |
dateTimePeriod | MPI07 | 2000C/D 2100C/D | Date Time Period Format CCYYMMDD MPI106=D8 | 1/35 S |
startDateTimePeriod | MPI08 | 2000C/D 2100C/D | Date Time Period Format CCYYMMDD- CCYYMMDD MPI106=RD8 | 1/35 S |
endDateTimePeriod | MPI08 | 2000C/D 2100C/D | Date Time Period Format CCYYMMDD- CCYYMMDD MPI106=RD8 | 1/35 S |
| 2110C - Subscriber Eligibility and Benefit Inquiry | See 270/271 Implementation Guide, p. 138 for details | |||
spendDownAmount | AMT02 | 2100C | Spend Down Amount AMT01=R | 1/18 S |
spendDownTotalBilledAmount | AMT02 | 2100C | Spend Down Total Billed Amount AMT01=PB | 1/18 S |
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
dependents (Object) | Use only when necessary. | S | ||
individualRelationshipCode | INS02 | 2100D | INS01=N Identifies the relationship to subscriber. Example: INS02 = 01 (Spouse) | 2/2 R |
birthSequenceNumber | INS17 | 2100D | Birth Sequence Number. 9 digit positive integer value | 1/9 R |
issueNumber | REF02 | 2100D | Issue Number. REF01=IF | 1/50 |
eligibilityCategory | REF02 | 2100D | Eligibility Category. REF01=MRC | 1/50 R |
firstName | NM104 | 2100C/D | Dependent’s first name. | 1/35 S |
lastName | NM103 | 2100C/D | Dependent’s last name. | 1/60 S |
middleName | NM105 | 2100C/D | 1/60 S | |
suffix | NM107 | 2100C/D | Dep. gender code. Options: F or M | 1/1 S |
dateOfBirth | DMG02 | 2100C/D | Dependent’s birth date. | 1/35 S |
gender | DMG03 | 2100C/D | Dependent’s gender code. F or M | 1/1 S |
ssn | REF02 | 2100D | Social Security value. REF01=SY | 1/50 S |
groupNumber | REF02 | 2100D | Group Number value: the subscriber’s group or policy number as specified on their insurance policy. REF01=6P | 1/50 R |
idCard | REF02 | 2100D | Identity Card value REF01=HJ | 1/50 R |
| Provider Information | ||||
providerCode | PRV01 | 2100C/D | Identifies provider type. AD = Admitting R if Ref Id PRV03 is provided. See annotation in OpenAPI spec. | 1/3 S |
referenceIdentificationQualifier | PRV02 | 2100C/D | Reference Identification Qualifier. Example: PXC = Health Care Provider Taxonomy Code | 2/3 S |
providerIdentifier | PRV03 | 2100C/D | Reference ID. See annotation in OpenAPI spec. | 1/50 S |
beginningCardIssueDate | DTP03 | 2100C/D | Beginning Card Issue Date DTP01=102 DTP02=RD8 YYYYMMDD- YYYYMMDD | 1/35 |
endCardIssueDate | DTP03 | 2100C/D | End Card Issue Date Format DTP01=102 DTP02=RD8 YYYYMMDD- YYYYMMDD | 1/35 |
idCardIssueDate | DTP03 | 2100C/D | ID issue date. Format: YYYYMMDD DTP01=102 DTP02=D8 | 1/35 S |
planIssueDate | DTP03 | 2100C/D | Plan issue date. Format: YYYYMMDD DTP01=291 DTP02=D8 | 1/35 |
beginningPlanIssueDate | DTP03 | 2100C/D | Beginning Plan Issue Date Format: YYYYMMDD- YYYYMMDD DTP01=291 DTP02=RD8 | 1/35 |
endPlanIssueDate | DTP03 | 2100C/D | End Plan Issue Date | 1/35 |
healthCareCodeInformation(Array of Objects) | Send health care codes with dates, quantities and amounts. If used, some attributes are required. HI01 to HI08 have the same segments. | S | ||
diagnosisTypeCode | HI01-1 | 2100C/D | Diagnosis Type Code Example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec | 1/3 R |
diagnosisCode | HI01-2 | 2100C/D | Diagnosis Code, indicates a code from a specific industry code list. See annotation in OpenAPI spec | 1/30 R |
address (object) | ||||
address1 | N301 | 2100C/D | Dependent’s address line 1. | 1/35 R* |
address2 | N302 | 2100C/D | Dependent’s address line 2. | 1/35 S |
city | N401 | 2100C/D | Dependent’s city. | 1/60 R* |
state | N402 | 2100C/D | Dependent’s state. | 1/35 S |
postalCode | N403 | 2100C/D | Dependent’s postal code. | 3/15 S |
| For dependents, one of the following REF02 ID’s is required. | ||||
additionalIdentification (Object) | ||||
planNumber | REF02 | 2100C/D | Plan Number. REF01=18 | 1/50 |
policyNumber | REF02 | 2100C/D | Group or Policy Number. REF01=1L | 1/50 |
memberIdentificationNumber | REF02 | 2100C/D | Member Identification Number. REF01=1W | 1/50 |
contractNumber | REF02 | 2100C | Contract Number. REF01=CT | 1/50 |
medicalRecordIdentificationNumber | REF02 | 2100C/D | Medical Record Identification Number. REF01=EA | 1/50 |
patientAccountNumber | REF02 | 2100C/D | Patient Account Number. REF01=EJ | 1/50 |
healthInsuranceClaimNumber | REF02 | 2100C/D | Health Insurance Claim (HIC) Number. REF01=F6 | 1/50 |
identificationCardSerialNumber | REF02 | 2100C/D | Identification Card Serial Number. REF01=GH | 1/50 |
insurancePolicyNumber | REF02 | 2100C/D | Insurance Policy Number. REF01=IG | 1/50 |
planNetworkIdentificationNumber | REF02 | 2100C/D | Plan Network Identification Number. REF01=N6 | 1/50 |
agencyClaimNumber | REF02 | 2100C/D | Agency Claim Number. REF01=Y4 | 1/50 |
Information applies to either Subscriber (2100C) or Dependent (2100D).
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
encounter (Object) | NOTE: 1st time encounter and any additional encounters. Contains claim/encounter information. Example: doctor visit. Depending on the request, will be for subscriber or dependent. Generic for: 2100C - Subscriber 2100D - Dependent DTP01=291 | R | ||
dateOfService | DTP03 | 2100C/D | Single date of service. Format: YYYYMMDD DTP02 = D8 | 1/35 S |
beginningDateOfService | DTP03 | 2100C/D | Date Time Period: Start Date Format: YYYYMMDD DTP02 = RD8 | 1/35 S |
endDateOfService | DTP03 | 2100C/D | Date Time Period: End Date Format: YYYYMMDD DTP02 = RD8 | 1/35 S |
serviceTypeCodes | EQ01 | 2110C/D | Subscriber or dependent eligibility service type code. EQ01 not Used if EQ02 is used. EQ02 – 1 and EQ02 – 2 are REQUIRED if using EQ02. | 1/2 S |
productOrServiceIDQualifier | EQ02-1 | 2110C/D | Product/ServiceID Qualifier code. Example: AD (American Dental Association Codes) | 2/2 S |
procedureCode | EQ02-2 | 2110C/D | Procedure Code | 1/48 S |
procedureModifiers | List of EQ02–3 EQ02–4 EQ02–5 EQ02–6 | 2110C/D | Procedure Modifier | 2/2 |
diagnosisCodePointer | List of EQ05–1 EQ05–2 EQ05–3 EQ05–4 | 2110C/D | Diagnosis Code Pointer | 1/2 |
industryCode | III02 | 2110C/D | Industry Code identifying a place of service. Examples on p. 142, Consolidated 270/271 Guide | 1/30 R |
referenceIdentificationQualifier | REF01 | 2110C/D | Reference Identification. Qualifier Example: 9F (Referral Number) | 2/3 R |
priorAuthorizationOrReferralNumber | REF02 | 2110C/D | Reference Identification. | 1/50 |
| Name | Description |
|---|---|
controlNumber | Provided by the submitter in the 270 Request. Transaction Set Control Number. |
reassociationKey | Reassociates the response to the original transaction. |
tradingPartnerServiceId | ID used by clearinghouse for the trading partner. |
See Page 252 of the 270/271 Implementation Guide for further detail.
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
subscriberTraceNumber (Object) | Identify a transaction to the payer. | S | ||
traceTypeCode | TRN01 | 2000C/D | Defines the referenced transaction. | 1/2 R |
traceType | TRN02 | 2000C/D | Describes the trace number type. | 1/50 R |
referenceIdentification | TRN04 | 2000C/D | Trace number used in the 270 TRN segment, or used by payer for more-specific identification. Based on value in TRN01. | 10/10 S |
originatingCompanyIdentifier | TRN03 | 2000C/D | Identifies the company that assigned the trace number, or shows the value from the 270 request. Based on value in TRN01. | 10/10 R |
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| Payer | Requires one of the following NM101 IDs. | |||
entityIdentifier | NM101 | 2100A | Third-Party Administrator: NM101=2B Employer: NM101=36 Gateway Provider NM101=GP Plan Sponsor NM101=P5 Payer NM101=PR | 2/3 S |
| Entity Identifier Code | Requires one of the following NM102 IDs: | |||
entityType | NM102 | 2100A | Person: NM102=1 Non-Person Entity: NM102=2 | 1/1 R |
name | NM103 | 2100A | Payer’s organization name. Can use organization or last name. | 1/60 R |
lastName | NM103 | 2100A | Payer’s last name. Can use organization or last name. | 1/60 R |
firstName | NM104 | 2100A | Payer first name | 1/35 S |
middleName | NM105 | 2100A | Payer Middle Name | 1/25 S |
suffix | NM107 | 2100A | Payer Name Suffix | 1/10 S |
| Identification Code | One of the following NM109 ID’s is required. | |||
employersIdETINfederalTaxpayersIdNumberNAICpayorIdentificationcentersForMedicareAndMedicaidPlanIdnpi | NM109 | 2100A | NM108=24 NM108=46 NM108=FI NM108=NI NM108=PI NM108=XV NM108=XX | 2/80 S |
| Information Receiver Provider Information | ||||
informationContact | PER01 | 2100A | Information Contact PER01=IC | 2/2 R |
name | PER02 | 2100A | Information Source Contact Name | 1/60 S |
Information Receiver Detail
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| Provider | ||||
entityIdentifier | NM101 | 2100C/D | One of the following NM101 ID’s is required: Provider: NM101=1P Third-Party Administrator: NM101=2B Employer: NM101=36 Hospital: NM101=80 Facility: NM101=FA Gateway Provider: NM101=GP Plan Sponsor: NM101=P5 Payer: NM101=PR | 2/3 S |
| Entity Identifier Code | One of the following NM102 ID’s is required. | |||
entityType | NM102 | 2100C/D | Person - NM102=1 Non-Person Entity - NM102=2 | 1/1 R |
name | NM103 | 2100C/D | Payer’s organization name. Can use organization or last name. | 1/60 R |
lastName | NM103 | 2100C/D | Payer’s last name. Can use organization or last name. | 1/60 R |
firstName | NM104 | 2100C/D | Payer first name. | 1/35 S |
middleName | NM105 | 2100C/D | Payer Middle Name | 1/25 S |
suffix | NM107 | 2100C/D | Payer Name Suffix | 1/10 S |
| Identification Code | Requires one of the following NM109 ID’s: | |||
employersIdssnfederalTaxpayersIdNumberpayorIdentificationpharmacyProcessorNumberserviceProviderNumberservicesPlanIdnpi | NM109 | 2100C/D | Employer’s Ident'n Number: NM108=24 Electronic Transmitter Ident'n Number (ETIN): NM108=34 Federal Taxpayer’s Ident'n Number: NM108=FI Payer Ident'n Number: NM108=PI Pharmacy Processor Number: NM108=PP Service Provider Number: NM108=SV Centers for Medicare and Medicaid Svc's PlanID: NM108=XV Centers for Medicare and Medicaid Services National Provider ID: NM108=XX | 2/80 R |
| Information Receiver Address | S | |||
address1 | N301 | 2100C/D | Provider address line 1 | 1/35 R |
address2 | N302 | 2100C/D | Provider address line 2 | 1/35 S |
city | N401 | 2100C/D | Provider city | 1/60 R |
state | N402 | 2100C/D | Provider’s state | 1/35 S |
postalCode | N403 | 2100C/D | Provider’s postal code | 1/1 S |
| Information Receiver Additional Identification | S | |||
providerCode | PRV01 | 2100C/D | Provider Code identifies the provider type | 1/3 R |
referenceIdentificationQualifier | PRV02 | 2100C/D | Reference Identification Qualifier. PRV02=PXC | 2/3 S |
referenceIdentification | PRV03 | 2100C/D | Provider Identifier | 1/50 S |
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
subscriber (Object) | R | |||
memberId | NM109 | 2100C | Member ID for the subscriber. NM108=MI | 2/80 S |
firstName | NM104 | 2100C | Subscriber’s first name as shown on their policy | 1/35 R |
lastName | NM103 | 2100C | Subscriber’s last name as shown on their policy | 1/60 S |
suffix | NM107 | 2100C | Subscriber’s Name Suffix | 1/10 S |
| Subscriber Additional Identification | One of the following REF02 ID’s is required. | R | ||
groupNumber | REF02 | 2100C | The subscriber group or policy number. REF01=6P | 1/50 |
idCard | REF02 | 2100C | Identity Card value. REF01=HJ | 1/50 |
ssn | REF02 | 2100C | Social Security value. REF01=SY | 1/50 |
caseNumber | REF02 | 2100C | Case Number. REF01=3H | 1/50 |
medicaidRecipientIdentificationNumber | REF02 | 2100C | Medicaid Recipient Identification Number. REF01=NQ | 1/50 |
planNumber | REF02 | 2100C | Plan Number. REF01=18 | 1/50 |
policyNumber | REF02 | 2100C | Group or Policy Number. REF01=1L | 1/50 |
memberIdentificationNumber | REF02 | 2100C | Member Identification Number. REF01=1W | 1/50 |
contractNumber | REF02 | 2100C | Contract Number. REF01=CT | 1/50 |
medicalRecordIdentificationNumber | REF02 | 2100C | Medical Record Identification Number. REF01=EA | 1/50 |
patientAccountNumber | REF02 | 2100C | Patient Account Number. REF01=EJ | 1/50 |
healthInsuranceClaimNumber | REF02 | 2100C | Health Insurance Claim (HIC) Number. REF01=F6 | 1/50 |
identificationCardSerialNumber | REF02 | 2100C | Identification Card Serial Number. REF01=GH | 1/50 |
insurancePolicyNumber | REF02 | 2100C | Insurance Policy Number. REF01=IG | 1/50 |
planNetworkIdentificationNumber | REF02 | 2100C | Plan Network Identification Number. REF01=N6 | 1/50 |
agencyClaimNumber | REF02 | 2100C | Agency Claim Number. REF01=Y4 | 1/50 |
subscriberAddress (Object) | ||||
address1 | N301 | 2100C | Subscriber’s address line 1. | 1/35 R |
address2 | N302 | 2100C | Subscriber’s address line 2. | 1/35 S |
city | N401 | 2100C | Subscriber’s city. | 1/60 R |
state | N402 | 2100C | Subscriber’s state. | 1/35 S |
postalCode | N403 | 2100C | Subscriber’s postal code. | 3/15 S |
| Provider Information | S | |||
providerCode | PRV01 | 2100C/D | Identifies the type of provider. Example: AD = Admitting Required if Ref Id PRV03 is provided. See annotation in OpenAPI spec. | 1/3 R |
referenceIdentificationQualifier | PRV02 | 2100C/D | Reference Identification Qualifier. | 2/3 S |
providerIdentifier | PRV03 | 2100C/D | Reference Identification. See annotation in OpenAPI spec. | 1/50 S |
| Subscriber Demographic Information | S | |||
dateOfBirth | DMG02 | 2100C/D | Subscriber’s birth date as specified on their policy. Format: YYYYMMDD | 1/35 S |
gender | DMG03 | 2100C/D | Subscriber’s gender as specified on their policy. Value: M or F | 1/1 S |
| Subscriber Health Care Code Information | S | |||
healthCareCodeInformation (Array of objects) | DTP03 | 2100C/D | Use to send health care codes with dates, quantities and amounts as needed. If used, requires specific attributes. HI01 to HI08 have same segments. | R |
healthCareDiagnosisCode (Object) | S | |||
diagnosisTypeCode | HI01-1 | 2100D | Diagnosis Type Code. | 1/3 R |
diagnosisCode | HI01-2 | 2100D | Diagnosis Code. | 1/30 R |
| Subscriber Relationship | S | |||
insuredIndicator | INS01 | 2000C/D 2100C/D | Insurance Indicator. INS01=Y | 1/1 R |
RelationToSubscriber | INS02 | 2000C/D 2100C/D | Individual Relationship Code INS02=18. | 2/2 R |
maintenanceTypeCode | INS03 | 2000C/D 2100C/D | Maintenance Type Code. INS03=001. | 3/3 S |
maintenanceReasonCode | INS04 | 2000C/D 2100C/D | Maintenance Reason Code INS04=25. | 2/3 S |
birthSequenceNumber | INS17 | 2000C/D 2100C/D | Subscriber’s Birth Sequence Number. | 1/9 S |
| Subscriber’s Military Personal Information | S | |||
informationStatusCode | MPI01 | 2000C/D 2100C/D | Information Status Code. | 1/1 R |
employmentStatusCode | MPI02 | 2000C/D 2100C/D | Employment Status Code. | 2/2 R |
governmentServiceAffiliationCode | MPI03 | 2000C/D 2100C/D | Government Service Affiliation Code. | 1/1 R |
description | MPI04 | 2000C/D 2100C/D | Description field. | 1/80 S |
militaryServiceRankCode | MPI05 | 2000C/D 2100C/D | Military Service Rank Code. | 2/2 S |
dateTimeFormatQualifier | MPI06 | 2000C/D 2100C/D | Date Time Format Qualifier. MPI106=D8, MPI106=RD8 | 2/3 S |
dateTimePeriod | MPI07 | 2000C/D 2100C/D | Date Time Period Format CCYYMMDD. MPI106=D8 | 1/35 S |
startDateTimePeriod | MPI08 | 2000C/D 2100C/D | Date Time Period Format CCYYMMDD-CCYYMMDD. MPI106=RD8 | 1/35 S |
endDateTimePeriod | MPI08 | 2000C/D 2100C/D | Date Time Period Format CCYYMMDD-CCYYMMDD. MPI106=RD8 | 1/35 S |
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
| For all attributes, also see annotations in our OpenAPI spec. | S | |||
dependents (Object) | ||||
firstName | NM104 | 2100C/D | Dependent’s first name. | 1/35 S |
lastName | NM103 | 2100C/D | Dependent’s last name. | 1/60 S |
middleName | NM105 | 2100C/D | Dependent’s Middle Name | 1/25 S |
suffix | NM107 | 2100C/D | Dependent’s Name Suffix | 1/10 S |
groupNumber | REF02 | 2100C/D | Subscriber's group or policy number as specified on their policy. REF01=6P | 1/50 R |
idCard | REF02 | 2100C/D | Identity Card value. REF01=HJ | 1/50 S |
ssn | REF02 | 2100C/D | Social Security value. REF01=SY | 1/50 S |
dateOfBirth | DMG02 | 2100C/D | Dependent’s birth date as specified on their policy. Format: YYYYMMDD | 1/35 |
gender | DMG03 | 2100C/D | Dependent’s gender as specified on their policy. Value: M or F | 1/1 |
address (Object) | S | |||
address1 | N301 | 2100C/D | Dependent’s address line 1 | 1/35 R |
address2 | N302 | 2100C/D | Dependent’s address line 2 | 1/35 S |
city | N401 | 2100C/D | Dependent’s city | 1/60 R |
state | N402 | 2100C/D | Dependent’s state | 1/35 S |
postalCode | N403 | 2100C/D | Dependent’s postal code | 3/15 S |
| Provider Information | S | |||
providerCode | PRV01 | 2100C/D | Provider Code: Identifies the provider type. See OpenAPI spec | 1/3 R |
referenceIdentificationQualifier | PRV02 | PRV02=PXC | 2/3 S | |
ReferenceIdentification | PRV03 | Provider Identifier | 1/50 S | |
| Dependent’s Relationship | S | |||
insuredIndicator | INS01 | 2000C/D 2100C/D | Insurance Indicator INS01=Y | 1/1 R |
relationToSubscriber | INS02 | 2000C/D 2100C/D | Relationship Code INS02=18 | 2/2 R |
maintenanceTypeCode | INS03 | 2000C/D 2100C/D | Maintenance Type Code INS03=001 | 3/3 S |
maintenanceReasonCode | INS04 | 2000C/D 2100C/D | Maintenance Reason Code INS04=25 | 2/3 S |
birthSequenceNumber | INS17 | 2000C/D 2100C/D | Subscriber’s Birth Sequence Number | 1/9 S |
| Dependent’s Health Care Diagnosis Code | ||||
healthCareCodeInformation (Object) | HI01-08 | HI01-HI08 have same segments | R | |
diagnosisTypeCode | HI01-1 | 2100C/D | Diagnosis Type Code | 1/3 R |
diagnosisCode | HI01-2 | 2100C/D | Diagnosis Code | 1/30 R |
| Dependent’s Military Personal Information | Use only when necessary | S | ||
informationStatusCode | MPI01 | 2000C/D 2100C/D | Information Status Code | 1/1 R |
employmentStatusCode | MPI02 | 2000C/D 2100C/D | Employment Status Code | 2/2 |
governmentServiceAffiliationCode | MPI03 | 2000C/D 2100C/D | Government Service Affiliation Code | 1/1 R |
description | MPI04 | 2000C/D 2100C/D | Description field | 1/80 S |
militaryServiceRankCode | MPI05 | 2000C/D 2100C/D | Military Service Rank Code | 2/2 S |
dateTimeFormatQualifier | MPI06 | 2000C/D 2100C/D | Date Time Format Qualifier MPI106=D8, MPI106=RD8 | 2/3 S |
dateTimePeriod | MPI07 | 2000C/D 2100C/D | Date-Time Period Format CCYYMMDD MPI106=D8 | 1/35 S |
startDateTimePeriod | MPI08 | 2000C/D 2100C/D | Date Time Period Format CCYYMMDD-CCYYMMDD MPI106=RD8 | 1/35 S |
endDateTimePeriod | MPI08 | 2000C/D 2100C/D | Date Time Period Format CCYYMMDD- CCYYMMDD MPI106=RD8 | 1/35 S |
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
planInformation (Object) | This field states the reference number type that follows in Element REF02. Depending on eligibility, it will be for the subscriber or the dependent. Subscriber = Loop 2100C; Dependent = Loop 2100D. Maps to REF02. | 1-50 R | ||
planNumber | REF02 | 2100C/D | REF01=18 | 1-50 |
policyNumber | REF02 | 2100C/D | REF01=1L | 1-50 |
memberId | REF02 | 2100C/D | REF01=1W | 1-50 |
caseNumber | REF02 | 2100C/D | REF01=3H | 1-50 |
familyUnitNumber | REF02 | 2100C/D | REF01=49 | 1-50 |
groupNumber | REF02 | 2100C/D | REF01=6P | 1-50 |
classOfContractCode | REF02 | 2100C/D | REF01=CE | 1-50 |
contractNumber | REF02 | 2100C/D | REF01=CT | 1-50 |
medicalRecordIdentificationNumber | REF02 | 2100C/D | REF01=EA | 1-50 |
patientAccountNumber | REF02 | 2100C/D | REF01=EJ | 1-50 |
hicNumber | REF02 | 2100C/D | REF01=F6 | 1-50 |
idCardSerialNumber | REF02 | 2100C/D | REF01=GH | 1-50 |
idCardNumber | REF02 | 2100C/D | REF01=HJ | 1-50 |
issueNumber | REF02 | 2100C/D | REF01=IF | 1-50 |
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
planDateInformation(Object) | This field describes the date or range of dates for the medical plan. Depending on eligibility, will be for subscriber or dependent. Subscriber = Loop 2100C; Dependent = Loop 2100D. Maps to DTP03. This information is also used in the benefitsDateInformation segment. All dates are in YYYYMMDD format | |||
discharge | DTP03 | 2100C | DTP01=096 | 1-50 R |
issue | DTP03 | 2100C | DTP01=102 | 1-50 |
effectiveDateOfChange | DTP03 | 2100C | DTP01=152 | 1-50 |
plan | DTP03 | 2100C | DTP01=291 | 1-50 |
eligibility | DTP03 | 2100C | DTP01=307 | 1-50 |
added | DTP03 | 2100C | DTP01=318 | 1-50 |
cobraBegin | DTP03 | 2100C | DTP01=340 | 1-50 |
cobraEnd | DTP03 | 2100C | DTP01=341 | 1-50 |
premiumPaidtoDateBegin | DTP03 | 2100C | DTP01=342 | 1-50 |
premiumPaidToDateEnd | DTP03 | 2100C | DTP01=343 | 1-50 |
planBegin | DTP03 | 2100C | DTP01=346 | 1-50 |
planEnd | DTP03 | 2100C | DTP01=347 | 1-50 |
eligibilityBegin | DTP03 | 2100C | DTP01=356 | 1-50 |
eligibilityEnd | DTP03 | 2100C | DTP01=357 | 1-50 |
enrollment | DTP03 | 2100C | DTP01=382 | 1-50 |
admission | DTP03 | 2100C | DTP01=435 | 1-50 |
dateOfDeath | DTP03 | 2100C | DTP01=442 | 1-50 |
certification | DTP03 | 2100C | DTP01=458 | 1-50 |
service | DTP03 | 2100C | DTP01=472 | 1-50 |
policyEffective | DTP03 | 2100C | DTP01=539 | 1-50 |
policyExpiration | DTP03 | 2100C | DTP01=540 | 1-50 |
dateOfLastUpdate | DTP03 | 2100C | DTP01=636 | 1-50 |
status | DTP03 | 2100C | DTP01=771 | 1-50 |
Deprecated
Please use
response.benefitsInformation.This was an aggregation attempt of EB segments that has proven to be problematic over time as it did not consider all the other meaningful elements of the EB segment, it is better to use the
response.benefitsInformationfor full details of the EB segments.
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
planStatus (Object) | Depending on eligibility, will be for subscriber or dependent. Subscriber = Loop 2110C; Dependent = Loop 2110D | R | ||
statusCode | EB01 | 2110C/D | Values can be 1 through 8. | 1/2 R |
status | EB01 | 2110C/D | The value of the status code. Example: statusCode = 1, then status = Active Coverage. | 1/50 |
planDetails | EB05 | 2110C/D | Description or number that identifies the plan or coverage. Value from EB05 | 1/50 S |
Applies for Subscriber (2110C) or Dependent (2110D). Date formats are YYYYMMDD for singular and YYYYMMDD-YYYYMMDD for range, qualified by the definition in DTP02. Benefits dating information, when needed, appears for each serviceTypes entry in a more-detailed benefits response. Dating applications for Eligibility benefits are similarly structured for a series of benefitsDateInformation types, to support requests for more complex benefits information including medical plan content (plan), deductibles, co-insurance, co-pays, exclusions, limitations, and other information. See Page 289-324 (Subscriber) and Page 393-398 of the 270/271 Implementation Guide for the full list of related codes.
| Name | Element | Description | Constraints | |
|---|---|---|---|---|
benefitsDateInformation (Object) | Required for describing dates for eligibility or benefits. Appears under each Benefit Description. | S | ||
discharge | DTP03 | Singular date entry. DTP=096 The singular discharge is deprecated; you will only receive the last occurrence of the 2110C/D loop. | 1/35 S | |
discharges (Array) | DTP03 | Discharge records appear when the Payer returns more than one discharge date. DTP01=096 | 1/35 S | |
date | DTP02 | Singular date for a facility discharge. DTP02=D8 | 8/17 S | |
startDate | DTP02 | Starting date for active service benefit. DTP02=RD8 | 8/8 S | |
endDate | DTP02 | Ending date for active service benefit. DTP02=RD8 | 8/8 S | |
admission | DTP03 | Singular date entry. The singular admission is deprecated; you will only receive the last occurrence of the 2110C/D loop. DTP01=435 | 1/35 S | 1/35 S |
admissions (Array) | DTP03 | Admissions records appear when the Payer returns more than one facility admissions date. DTP01=435 | 1/35 S | |
date | DTP02 | Singular date for an admission. DTP02=D8 | 8/17 S | |
startDate | DTP02 | Starting date for benefits if a range applies. DTP02=RD8 | 8/8 S | |
endDate | DTP02 | Ending date for benefits for the service if a range applies. DTP02=RD8 | 8/8 S |
Dates are listed in the order received from the payer.
| Name | DTP01 Value | DTP03 Displays... |
|---|---|---|
benefitsDateInformation (Object) | Date format: YYYYMMDD. | |
discharges | 096 | Discharge dates information, will return a singular discharge date or date range, or all dates or date ranges in a list where applicable. |
plan | 291 | Plan date. |
benefit | 292 | Benefit date. |
eligibility | 307 | Eligibility date. |
added | 318 | Added date. |
planBegin | 346 | Plan start date. |
eligibilityBegin | 356 | Eligibility start date. |
eligibilityEnd | 357 | Eligibility end date. |
admissions | 435 | Admission date(s). |
service | 472 | Service date. |
dateOfLastUpdate | 636 | Date of last update. |
status | 771 | Status date. |
| Name | Element | Loop | Description | Constraints |
|---|---|---|---|---|
benefitsInformation (Object) | See the OpenAPI spec for more on the attributes and values for this object. | S | ||
code | EB01 | 2110C/D | Code that identifies eligibility or benefits. | 1/2 R |
name | EB01 | 2110C/D | Name of the benefit. Example: For code B, benefit is Co-Payment. Some codes indicate patient responsibility. See Pages 295-98 of the 270/271 Implementation Guide for the list of codes. | 1/50 R |
coverageLevelCode | EB02 | 2110C/D | Code showing the coverage level for the insured. Ex: CHD | 3/3 S |
coverageLevel (Object) | EB02 | 2110C/D | Description of the insurance coverage. Ex: for code CHD, it displays Children Only | 1/50 |
serviceTypeCodes | EB03 | 2110C/D | Identifies classification of service. Example: 1. Unused if element EB13 is used in response | 1/2 S |
serviceTypes | EB03 | 2110C/D | Describes service type. Example: 1 = Medical Care. | 1/50 S |
insuranceTypeCode | EB04 | 2110C/D | Code that Identifies the type of insurance policy within a specific insurance program. | 1/3 S |
insuranceType | Definition of EB04 | 2110C/D | The name of the policy type in an insurance program. Example: code 12 = Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan. | 1/120 S |
planCoverage | EB05 | 2110C/D | Description or number identifying the plan or coverage. | 1/50 S |
timeQualifierCode | EB06 | 2110C/D | Code that qualifies the time period for coverage. Ex: 6 | 1/2 S |
timeQualifier | Definition of EB06 | 2110C/D | Description of EB06. Example: Code 6 = Hour. | 1/20 S |
benefitAmount | EB07 | 2110C/D | Patient responsibility. Example: deductible, co-payment | 1/18 S |
benefitPercent | EB08 | 2110C/D | Patient responsibility as percentage. | 1/10 S |
quantityQualifierCode | EB09 | 2110C/D | Code that specifies quantity type. | 2/2 S |
quantityQualifier | Definition of EB09 | 2110C/D | Description of EB09. Qualifies the benefits in the 2110C loop by quantity. See 270/271 Implementation guide, p. 37 for details. | 1/50 S |
benefitQuantity | EB10 | 2110C/D | Numeric value of the quantity. | 1/15 S |
authOrCertIndicator | EB11 | 2110C/D | Indicates whether authorization or certification is required per plan provisions. Value can be: Y (In Network)/N (Out of Network)/U (Unknown). | 1/1 S |
inplanNetworkIndicator | EB12 | 2110C/D | Indicates whether benefits are In Plan Network or Out of Plan Network. Values: N (Out of Network), U(Unknown), W (Not Applicable), Y (In Network). | 1/1 S |
compositeMedicalProcedureIdentifier(Object) | EB13 | 2110C/D | Not Used if using EB03. | |
ProductOrServiceIDQualifierCode | EB13-01 | 2100C/D | Identifies the type/source of the descriptive number used in Product/Service ID. Example: AD = American Dental Association Code | 2/2 R |
ProductOrServiceIDQualifier | EB13-01 | 2110C/D | Medical service or medical product qualifier. See 270/271 Implementation guide, p. 310 for details. | R |
procedureCode | EB13-02 | 2110C/D | Identifying Number for a Product or Service. | 1/48 R |
producerModifiers | EB13-03 EB13-04 EB13-05 EB13-06 | 2110C/D | Identifies special circumstances related to service performance, as defined by trading partners | 2/2 S |
productOrServiceID | EB13-08 | 2110C/D | For information source to describe a range of medical codes. See 270/271 Implementation guide, p. 312 for details. | 1/48 S |
| Composite Diagnosis Code Pointer | EB14 | 2110C/D | Identifies diagnosis Code pointers. | S |
diagnosisCodePointer | EB14-01 EB14-02 EB14-03 EB14-04 | 2110C/D | A pointer to the diagnosis code in order of importance to this service. | 1/2 |
| Loop Header | ||||
headerLoopIdentifierCode | LS01 | 2115C/D | A loop ID number. Indicates that the next segment begins a new loop, typically a nested loop. See 270/271 Implementation Guide, p. 334 for details. | 1/4 S |
| Loop Trailer | ||||
trailerLoopIdentifierCode | LE01 | 2120C/D | States that the loop preceding this segment is completed. The loop ID number must be the same as given in the loop header. See 270/271 Implementation Guide, p. 352 for details. | 1/4 S |
| Name | REF01 Value | Description | Constraints | |
|---|---|---|---|---|
| See the OpenAPI spec for more about this object. | ||||
benefitsAdditionalInformation (Object) | 2110C - Subscriber; 2110D - Dependent | 1/50 S | ||
| Subscriber | Dependent | REF02 Displays… | ||
planNumber | 18 | 18 | Plan Number | |
policyNumber | 1L | 1L | Group or Policy Number | |
memberId | 1W | 1W | Member ID Number | |
familyUnitNumber | 49 | 49 | Family Unit Number | |
groupNumber | 6P | 6P | Group Number | |
classOfContractCode | CE | Class of Contract Code (dependent) | ||
contractNumber | CT | Contract Number | ||
medicalRecordIdentificationNumber | EA | Medical Record ID Number | ||
patientAccountNumber | EJ | Patient Account Number | ||
hicNumber | F6 | F6 | Health insurance Claim (HIC) Number | |
idCardSerialNumber | GH | Identification Card Serial Number | ||
idCardNumber | HJ | Identify Card Number | ||
issueNumber | IF | Issue Number | ||
insurancePolicyNumber | IG | IG | Insurance Policy Number | |
planNetworkIdNumber | N6 | N6 | Plan Network ID | |
medicaidRecepientIdNumber | NQ | NQ | Medicaid Recipient ID Number | |
priorIdNumber | Q4 | Q4 | Prior ID Number | |
socialSecurityNumber | SY | Social Security Number | ||
agencyClaimNumber | Y4 | Agency Claim Number |
| Name | Element | Description | Constraints |
|---|---|---|---|
benefitsRelatedEntity (Object) | 2120C/D | Generic for: 2100A – Information Source Name; 2100B - Information Receiver Name; 2120C - Subscriber; 2120D - Dependent | |
entityIdentifier | NM101 | Displays the value of the Entity Identifier code. Example: If code is PR, then Payer displays. | 2/3 |
entityType | NM102 | Value is a person or organization; mapping to 1 or 2. 1 – Person 2 – Non-Person Entity (organization) | 1/1 |
entityName | NM103 | Last name or Organization Name. | 1/60 |
entityFirstname | NM104 | First name. | 1/35 |
entityMiddlename | NM105 | Middle Name. | 1/25 |
entitySuffix | NM106 | Suffix to individual name. | 1/10 |
entityIdentification | NM108 | Definition of the identification code of the entity. Example: if 34, ‘Social Security Number’ displays. | 2/80 |
entityIdentificationValue | NM109 | Displays the value of the entity identification. Example: if Social Security Number, then actual SSN value is shown. | 2/80 |
entityRelationship | NM110 | Displays the entity relationship. Example: if 01, ‘Parent’ displays. | 2/2 |
address (Object) | Location of the named party. | ||
address1 | N301 | Displays the first line of entity address information. | 1/55 |
address2 | N302 | Displays the second line of entity address information. | 1/55 |
city | N401 | Displays the name of the city. | 2/30 |
state | N402 | Displays the name of the state. | 2/2 |
postalCode | N403 | Displays the postal code. | 3/15 |
| Name | Element | Description |
|---|---|---|
benefitsRelatedEntities (Object) | 2120C/D | Array of benefitsRelatedEntity records. Contains all 2120C/D respective loops, while benefitsRelatedEntity above contains only the first loop. The singular benefitsRelatedEntity is deprecated; you will only receive the first occurrence of the 2120C/D loop. |
| Name | Value | Description | Constraint |
|---|---|---|---|
eligibilityAdditionalInformation (Object) | 2115C - Subscriber; 2115D – Dependent | ||
codeListQualifierCode | III01 | Identifies a specific industry code list Example: if code is ZZ, Mutually Defined. | 1/3 |
industryCode | III02 | Code indicating a code from a specific industry code list. Example: id code is 01, Pharmacy | 1/30 |
codeCategory | III03 | Specifies the situation or category where the code applies. R when III01 and III02 are not present. Value: 44 (Nature of Injury) | 2/2 |
injuredBodyPartName | III04 | R when III03 = ”44” | 1/264 |
| Name | Description |
|---|---|
eligibilityAdditionalInformationList (Object) | Array of eligibilityAdditionalInformation records, which contain all occurrences of 2115C/D. The singular eligibilityAdditionalInformation object is deprecated because it contains the first occurrence of the 2115C/D loops. |
| Name | Value | Description | Constraint | s |
|---|---|---|---|---|
contactInformation (Object) | 2100A - Information Source Name; 2120C - Subscriber; 2120D - Dependent. | |||
name | PER02 | Administrative communication contact name. | 1/60 S | |
communicationMode | PER03 | Type of communication. Example: TE is Telephone | S | |
communicationNumber | PER04 | First contact number, e-mail or web address. | 1/256 S | |
communicationMode | PER05 | Type of communication. Example: TE is Telephone. | S | |
communicationNumber | PER06 | Second contact number, e-mail or web address. | 1/256 S | |
communicationMode | PER07 | Type of communication. Example: TE is Telephone | S | |
communicationNumber | PER08 | Third contact number, e-mail or web address. | 1/256 S |
| Name | Value | Description | Constraint |
|---|---|---|---|
providerInformation (Object) | 2100B- Information Receiver Name; 2120C - Subscriber; 2120D – Dependent | ||
providerCode | PRV01 | Displays the provider type. Example: if code is AD, Admitting displays. | |
referenceIdentification | PRV03 | Healthcare Provider Taxonomy code value. | 1/50 |
HSD – Health Care Services Delivery
| Name | Value | Description | Constraints |
|---|---|---|---|
benefitsServiceDelivery (Object) | 2110C - Subscriber; 2110D - Dependent | ||
quantityQualifier | HSD01 | Specifies the quantity type. Example: DY – Days, FL – Units, VS - Visits | 2/2 |
quantity | HSD02 | Numeric value of quantity. | 1/15 |
unitForMeasurementCode | HSD03 | Measurement code unit or basis. Specifies the units that a value is expressed or taken. Examples: DA – Days, MO – Months | 2/2 |
sampleSelectionModulus | HSD04 | Specify the sampling frequency in terms of a modulus of the unit of measure. Examples: ever fifth bag, every 1.5 minutes | 1/6 |
timePeriodQualifier | HSD05 | Code defining periods. Examples: 6 – Hours, 7 – Day, 21 - Years | 1/2 |
numOfPeriods | HSD06 | Total number of periods. | 1/3 |
deliveryOrCalendarPatternCode | HSD07 | Code specifying the routine shipments, deliveries, or calendar pattern. Examples: 1 – 1st Week of the Month 2 – 2nd Week of the Month D - Monday | 1/2 |
deliveryPatternTimeCode | HSD08 | Code that specifies the time for routine shipments or deliveries. Examples: B – 2nd Shift G – Any Shift | 1/1 |
| Name | Value from | Description | Constraint |
|---|---|---|---|
additionalInformation | 2110C - Subscriber; 2110D - Dependent | ||
description | MSG01 | Value from MSG segment.MSG01 | 1/264 |
| Name | Description |
|---|---|
errorResponse (Object) | |
code | Code for the error. Example: INVALID_MISSING_INPUT_DATA |
description | Description of error code. Value provided in payer ID should be a valid Optum-assigned ERA payer Id. |
errors (Object) | |
field | Attribute that is bad. |
value | Value of that attribute. |
code | Code for the error. Example: INVALID_VALUE |
location | Segment/location where error occurred. If a network/system error, there is no location attribute. Example: $.payerBenefits[0].payer |
followupAction | Any follow action required for the error. For AAA errors, this would be the value for AAA04. |
NOTE
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