270/271 — Health Care Eligibility Benefit Inquiry and Response

The following information is associated with the information source, information receiver, subscriber, and dependent used in the following examples in this section:

Payer (Information Source): ABC Company

Payer Identification Number: 842610001

Provider (Information Receiver) Clinic: Bone and Joint Clinic

Service Provider Number: 2000035

Facility Network Identification Number: 234899

Address: 55 High Street Seattle, WA, 98123

Communication Contact Name: Billing Department

Phone Number: 206-555-1212

Extension: 2805

FAX: 206-555-1213

Provider (Information Receiver) Individual Physician: Marcus Jones

Service Provider Number: 0202034

Provider Plan Network Identification Number: 129

Communication Contact Name: M. Murphy

Phone Number: 206-555-1212

Extension: 3694

FAX: 206-555-1214

Subscriber (Subscriber/Patient): Robert B. Smith

Member Identification Number: 11122333301

Date of Birth: 19430519

Sex: Male

Group or Policy Number: 599119

Address: 29 Fremont St, Apt # 1, Peace, NY, 10023

Dependent (Patient): Mary Smith

Social Security Number: 003221234

Date of Birth: 19781014

Sex: Female

Relationship to Subscriber: Child