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Updated:05/16/2008

Dependent Eligibility or Benefit Information

Pos: 130	Max: 1
Detail - Optional
Loop: 2110D	Elements: 13

To supply eligibility or benefit information

Element Summary:


_Ref_	Id	_________Element Name__________			Req	Type	Min/Max
EB01	1390	Eligibility or Benefit Information			M	ID	1/2
		Description: Code identifying eligibility or benefit information
			Code	Name_______________________________
			1	Active Coverage
			2	Active - Full Risk Capitation
			3	Active - Services Capitated
			4	Active - Services Capitated to Primary Care Physician
			5	Active - Pending Investigation
			6	Inactive
			7	Inactive - Pending Eligibility Update
			8	Inactive - Pending Investigation
			A	Co-Insurance
			B	Co-Payment
			C	Deductible
			D	Benefit Description
			E	Exclusions
			F	Limitations
			G	Out of Pocket (Stop Loss)
			H	Unlimited
			I	Non-Covered
			J	Cost Containment
			K	Reserve
			L	Primary Care Provider
			M	Pre-existing Condition
			N	Services Restricted to Following Provider
			O	Not Deemed a Medical Necessity
			P	Benefit Disclaimer
			Q	Second Surgical Opinion Required
			R	Other or Additional Payor
			S	Prior Year(s) History
			T	Card(s) Reported Lost/Stolen
			U	Contact Following Entity for Eligibility or Benefit Information
			V	Cannot Process
			W	Other Source of Data
			X	Health Care Facility
			Y	Spend Down
			CB	Coverage Basis
			MC	Managed Care Coordinator
EB02	1207	Coverage Level Code			O	ID	3/3
		Description: Code indicating the level of coverage being provided for this insured
			Code	Name_______________________________
			CHD	Children Only
			DEP	Dependents Only
			ECH	Employee and Children
			ESP	Employee and Spouse
			FAM	Family
			IND	Individual
			SPC	Spouse and Children
			SPO	Spouse Only
EB03	1365	Service Type Code			O	ID	1/2
		Description: Code identifying the classification of service
			Code	Name_______________________________
			1	Medical Care
			2	Surgical
			3	Consultation
			4	Diagnostic X-Ray
			5	Diagnostic Lab
			6	Radiation Therapy
			7	Anesthesia
			8	Surgical Assistance
			9	Other Medical
			10	Blood Charges
			11	Used Durable Medical Equipment
			12	Durable Medical Equipment Purchase
			13	Ambulatory Service Center Facility
			14	Renal Supplies in the Home
			15	Alternate Method Dialysis
			16	Chronic Renal Disease (CRD) Equipment
			17	Pre-Admission Testing
			18	Durable Medical Equipment Rental
			19	Pneumonia Vaccine
			20	Second Surgical Opinion
			21	Third Surgical Opinion
			22	Social Work
			23	Diagnostic Dental
			24	Periodontics
			25	Restorative
			26	Endodontics
			27	Maxillofacial Prosthetics
			28	Adjunctive Dental Services
			30	Health Benefit Plan Coverage
			32	Plan Waiting Period
			33	Chiropractic
			34	Chiropractic Office Visits
			35	Dental Care
			36	Dental Crowns
			37	Dental Accident
			38	Orthodontics
			39	Prosthodontics
			40	Oral Surgery
			41	Routine (Preventive) Dental
			42	Home Health Care
			43	Home Health Prescriptions
			44	Home Health Visits
			45	Hospice
			46	Respite Care
			47	Hospital
			48	Hospital - Inpatient
			49	Hospital - Room and Board
			50	Hospital - Outpatient
			51	Hospital - Emergency Accident
			52	Hospital - Emergency Medical
			53	Hospital - Ambulatory Surgical
			54	Long Term Care
			55	Major Medical
			56	Medically Related Transportation
			57	Air Transportation
			58	Cabulance
			59	Licensed Ambulance
			60	General Benefits
			61	In-vitro Fertilization
			62	MRI/CAT Scan
			63	Donor Procedures
			64	Acupuncture
			65	Newborn Care
			66	Pathology
			67	Smoking Cessation
			68	Well Baby Care
			69	Maternity
			70	Transplants
			71	Audiology Exam
			72	Inhalation Therapy
			73	Diagnostic Medical
			74	Private Duty Nursing
			75	Prosthetic Device
			76	Dialysis
			77	Otological Exam
			78	Chemotherapy
			79	Allergy Testing
			80	Immunizations
			81	Routine Physical
			82	Family Planning
			83	Infertility
			84	Abortion
			85	AIDS
			86	Emergency Services
			87	Cancer
			88	Pharmacy
			89	Free Standing Prescription Drug
			90	Mail Order Prescription Drug
			91	Brand Name Prescription Drug
			92	Generic Prescription Drug
			93	Podiatry
			94	Podiatry - Office Visits
			95	Podiatry - Nursing Home Visits
			96	Professional (Physician)
			97	Anesthesiologist
			98	Professional (Physician) Visit - Office
			99	Professional (Physician) Visit - Inpatient
			A0	Professional (Physician) Visit - Outpatient
			A1	Professional (Physician) Visit - Nursing Home
			A2	Professional (Physician) Visit - Skilled Nursing Facility
			A3	Professional (Physician) Visit - Home
			A4	Psychiatric
			A5	Psychiatric - Room and Board
			A6	Psychotherapy
			A7	Psychiatric - Inpatient
			A8	Psychiatric - Outpatient
			A9	Rehabilitation
			AA	Rehabilitation - Room and Board
			AB	Rehabilitation - Inpatient
			AC	Rehabilitation - Outpatient
			AD	Occupational Therapy
			AE	Physical Medicine
			AF	Speech Therapy
			AG	Skilled Nursing Care
			AH	Skilled Nursing Care - Room and Board
			AI	Substance Abuse
			AJ	Alcoholism
			AK	Drug Addiction
			AL	Vision (Optometry)
			AM	Frames
			AN	Routine Exam
			AO	Lenses
			AQ	Nonmedically Necessary Physical
				Description: These physicals are required by other entities e.g., insurance application, pilot license, employment or school
			AR	Experimental Drug Therapy
			BA	Independent Medical Evaluation
			BB	Partial Hospitalization (Psychiatric)
			BC	Day Care (Psychiatric)
			BD	Cognitive Therapy
			BE	Massage Therapy
			BF	Pulmonary Rehabilitation
			BG	Cardiac Rehabilitation
			BH	Pediatric
			BI	Nursery
			BJ	Skin
			BK	Orthopedic
			BL	Cardiac
			BM	Lymphatic
			BN	Gastrointestinal
			BP	Endocrine
			BQ	Neurology
			BR	Eye
			BS	Invasive Procedures
EB04	1336	Insurance Type Code			O	ID	1/3
		Description: Code identifying the type of insurance policy within a specific insurance program
			Code	Name_______________________________
			D	Disability
				Description: Provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury or disease
			12	Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
			13	Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan
			14	Medicare Secondary, No-fault Insurance including Auto is Primary
			15	Medicare Secondary Worker's Compensation
			16	Medicare Secondary Public Health Service (PHS)or Other Federal Agency
			41	Medicare Secondary Black Lung
			42	Medicare Secondary Veteran's Administration
			43	Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
			47	Medicare Secondary, Other Liability Insurance is Primary
			AP	Auto Insurance Policy
			C1	Commercial
			CO	Consolidated Omnibus Budget Reconciliation Act (COBRA)
			CP	Medicare Conditionally Primary
			DB	Disability Benefits
			EP	Exclusive Provider Organization
				Description: Gives subscriber a choice of providers from an approved/contracted payer list; there are fixed dollar co-payments for most covered services in return for using plan providers
			FF	Family or Friends
			GP	Group Policy
				Description: Two or more people who are part of complete unit who enter into an insurance contract with an insurance company
			HM	Health Maintenance Organization (HMO)
			HN	Health Maintenance Organization (HMO) - Medicare Risk
			HS	Special Low Income Medicare Beneficiary
				Description: An individual eligible for Medicare for whom Medicaid pays only Medicare premiums
			IN	Indemnity
				Description: Gives a subscriber the choice to select any provider. Payment is fixed percentage of the cost for covered care after satisfying an annual deductible
			IP	Individual Policy
			LC	Long Term Care
				Description: Coverage designed to help pay for some or all long term care costs, reducing the risk that a policy-holder would need to deplete all of his or her assets to pay for long term care
			LD	Long Term Policy
			LI	Life Insurance
			LT	Litigation
			MA	Medicare Part A
			MB	Medicare Part B
			MC	Medicaid
				Description: Program of health care services made available to medically indigent and other needy persons, regardless of age, under terms of a 1965 amendment to the U.S. Social Security Act
			MH	Medigap Part A
				Description: Health insurance policy intended to cover the non-covered portion of expenses eligible for Medicare Part A reimbursement which must be paid by a Medicare beneficiary for health care services and/or supplies received
			MI	Medigap Part B
				Description: Health insurance policy intended to cover the non-covered portion of expenses eligible for Medicare Part B reimbursement which must be paid by a Medicare beneficiary for health care services and/or supplies received
			MP	Medicare Primary
				Description: Medicare has the primary responsibility to pay for health care services and/or supplies received by a covered beneficiary (a person entitled to medicare benefits)
			OT	Other
			PE	Property Insurance - Personal
			PL	Personal
			PP	Personal Payment (Cash - No Insurance)
			PR	Preferred Provider Organization (PPO)
			PS	Point of Service (POS)
			QM	Qualified Medicare Beneficiary
				Description: Coverage for a Medicare eligible individual for whom Medicaid pays only for Medicare premiums, co-insurance, and deductibles
			RP	Property Insurance - Real
			SP	Supplemental Policy
				Description: An insurance policy intended to cover non-covered charges of another insurance policy
			TF	Tax Equity Fiscal Responsibility Act (TEFRA)
			WC	Workers Compensation
				Description: Coverage provides medical treatment, rehabilitation, lost wages and related expenses arising from a job related injury or disease
			WU	Wrap Up Policy
				Description: A Workers Compensation Policy written for a specific job site, which will include or cover more than one insured
EB05	1204	Plan Coverage Description			O	AN	1/50
		Description: A description or number that identifies the plan or coverage
EB06	615	Time Period Qualifier			O	ID	1/2
		Description: Code defining periods
			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			O	R	1/18
		Description: Monetary amount
EB08	954	Percent			O	R	1/10
		Description: Percentage expressed as a decimal
EB09	673	Quantity Qualifier			C	ID	2/2
		Description: Code specifying the type of quantity
			Code	Name_______________________________
			99	Quantity Used
				Description: Quantity of units used
			CA	Covered - Actual
				Description: Days covered on this service
			CE	Covered - Estimated
				Description: Estimated days covered on this service
			DB	Deductible Blood Units
				Description: Amount of blood units not reimbursed due to plan deductible limits
			DY	Days
			HS	Hours
			LA	Life-time Reserve - Actual
				Description: Medicare hospital insurance includes extra hospital days to be used if the patient has a long illness and is required to stay in the hospital over a specified number of days; this is the actual number of days in reserve
			LE	Life-time Reserve - Estimated
				Description: Medicare hospital insurance includes extra hospital days to be used if the patient has a long illness and is required to stay in the hospital over a specified number of days; this is an estimate of the number of days in reserve
			MN	Month
			P6	Number of Services or Procedures
			QA	Quantity Approved
				Description: Quantity allowed by the company processing the claim
			S7	Age, High Value
			S8	Age, Low Value
			VS	Visits
			YY	Years
EB10	380	Quantity			C	R	1/15
		Description: Numeric value of quantity
EB11	1073	Yes/No Condition or Response Code			O	ID	1/1
		Description: Code indicating a Yes or No condition or response
			Code	Name_______________________________
			N	No
			U	Unknown
			Y	Yes
EB12	1073	Yes/No Condition or Response Code			O	ID	1/1
		Description: Code indicating a Yes or No condition or response
			Code	Name_______________________________
			N	No
			U	Unknown
			Y	Yes
EB13	C003	Composite Medical Procedure Identifier			O	Comp
		Description: To identify a medical procedure by its standardized codes and applicable modifiers
	235	Product/Service ID Qualifier			M	ID	2/2
		Description: Code identifying the type/source of the descriptive number used in Product/Service ID (234)
			Code	Name_______________________________
			AD	American Dental Association Codes
				Description: This association's membership consists of U.S. dentists. It sets standards for the dental profession
			CJ	Current Procedural Terminology (CPT) Codes
				Description: Published by the AMA. It is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians; the uniform language accurately designates medical, surgical, and diagnostic services, and thereby provides reliable communications among physicians, patients, and payers
			HC	Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
				Description: HCFA coding scheme to group procedure(s) performed on an outpatient basis for payment to hospital under Medicare; primarily used for ambulatory surgical and other diagnostic departments
			ID	International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure
				Description: The International Classification of Diseases, Clinical Modification, is designated for the classification of morbidity and mortality information for statistical purposes and for the indexing of hospital records by disease and operations, for data storage and retrieval; this is a procedure code
			ND	National Drug Code (NDC)
			ZZ	Mutually Defined
	234	Product/Service ID			M	AN	1/48
		Description: Identifying number for a product or service
	1339	Procedure Modifier			O	AN	2/2
		Description: This identifies special circumstances related to the performance of the service, as defined by trading partners
	1339	Procedure Modifier			O	AN	2/2
		Description: This identifies special circumstances related to the performance of the service, as defined by trading partners
	1339	Procedure Modifier			O	AN	2/2
		Description: This identifies special circumstances related to the performance of the service, as defined by trading partners
	1339	Procedure Modifier			O	AN	2/2
		Description: This identifies special circumstances related to the performance of the service, as defined by trading partners

Transaction Set

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