Section title: X12 EDI Examples
back to previous

ASC X12 Version: 005010 | Transaction Set: 270/271 | TR3 ID: 005010X279

Example 2a: Generic Request by a Physician for the Patient’s (Dependent) Eligibility

This is an example of an eligibility request from an individual provider to a payer. The physician is inquiring if the patient (the dependent) has coverage. The request is from Marcus Jones to the ABC Company. This example uses the Primary Search Option (see Section 1.4.8 - Search Options) for a dependent who is the patient and is for a generic request for Eligibility (see Section 1.4.7 - Implementation-Compliant Use of the 270/271 Transaction Set).

Transmission Explanation

ST*270*1235*005010X279A1~

Transaction Set ID Code = 270 (Eligibility, Coverage or Benefit Inquiry)

Transaction Set Control Number = 1235

Implementation Convention Reference = 005010X279A1

BHT*0022*13*10001235*20060501*1320~

Hierarchical Structure Code = 0022 (Information Source, Information Receiver, Subscriber, Dependent)

Transaction Set Purpose Code = 13 (Request) Identification

Reference Identification = 10001235

Date = 20060501 (May 1, 2006)

Time = 1:20 PM

HL*1**20*1~

Hierarchical ID Number = 1

Hierarchical Parent ID Number = * not used

Hierarchical Level Code = 20 (Information Source)

Hierarchical Child Code = 1

NM1*PR*2*ABC COMPANY*****PI*842610001~

Entity Identifier Code = PR (Payer)

Entity Type Qualifier = 2 (Non-person)

Last Name = ABC Company

First Name = * not used

Middle Name = * not used

Name Prefix = * not used

Name Suffix = * not used

Identification Code Qualifier = PI (Payer Identification)

Identification Code = 842610001

HL*2*1*21*1~

Hierarchical ID Number = 2

Hierarchical Parent ID Number = 1

Hierarchical Level Code = 21

Hierarchical Child Code = 1

NM1*1P*1*JONES*MARCUS****SV*0202034~

Entity Identifier Code = 1P (Provider)

Entity Type Qualifier = 1 (Person)

Last Name = Jones

First Name = Marcus

Middle Name = * not used

Name Prefix = * not used

Name Suffix = * not used

Identification Code Qualifier = SV Service Provider Number

Identification Code = 0202034

HL*3*2*22*1~

Hierarchical ID Number = 3

Hierarchical Parent ID Number = 2

Hierarchical Level Code = 21

Hierarchical Child Code = 1

NM1*IL*1******MI*11122333301~

Entity Identifier Code = IL (Insured or Subscriber)

Entity Type Qualifier = 1 (Person)

Last Name = * not used

First Name = * not used

Middle Name = * not used

Name Prefix = * not used

Name Suffix = * not used

Identification Code Qualifier = MI (Member Identification Number)

Identification Code = 11122333301

HL*4*3*23*0~

Hierarchical ID Number = 4

Hierarchical Parent ID Number = 3

Hierarchical Level Code = 23

Hierarchical Child Code = 0

TRN*1*93175-012547*9877281234~

Trace Type Code = 1 (Current Transaction Trace Number)

Reference Identification = 93175-012547

Originating Company Identifier = 9877281234

Reference Identification = * not used

NM1*03*1*SMITH*MARY~

Entity Identifier Code = 03 (Dependent)

Entity Type Qualifier = 1 (Person)

Last Name = Smith

First Name = Mary

Middle Name = * not used

Name Prefix = * not used

Name Suffix = * not used

Identification Code Qualifier = * not used

Identification Code = * not used

DMG*D8*19781014~

Date Time Period Format = D8 (Date Expressed in Format CCYYMMDD)

Date Time Period = 19781014

DTP*291*D8*20060501~

Date/Time Qualifier = 291 (Plan)

Date Time Period Format Qualifier D8 (Dates Expressed in Format CCYYMMDD)

Date Time Period = 20060501(May 1, 2006)

EQ*30~

Service Type Code = 30 (Health Benefit Plan Coverage

SE*15*1235~

Number of Included Segments = 15

Transaction Set Control Number = 1235