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Updated:09/19/2008

HIPAA 270 Eligibility, Coverage or Benefit Inquiry
Management Systems Consulting, Inc.
VERSION: 1.0 DRAFT

Author: Skip Stein

Notes: In order to protect the security and confidentiality of electronic health information, Congress has passed The Health Insurance Portability and Accountability Act, also known as HIPAA, which was the result of efforts by the Clinton Administration and congressional healthcare reform proponents to reform healthcare in a way that would streamline industry inefficiencies, reduce paperwork, make it easier to detect and prosecute fraud and abuse and enable workers of all professions to change jobs, even if they (or family members) had pre-existing medical conditions.

270
Eligibility, Coverage or Benefit Inquiry
Functional Group=HS

This Draft Standard for Trial Use contains the format and establishes the data contents of the Eligibility, Coverage or Benefit Inquiry Transaction Set (270) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to inquire about the eligibility, coverages or benefits associated with a benefit plan, employer, plan sponsor, subscriber or a dependent under the subscriber's policy. The transaction set is intended to be used by all lines of insurance such as Health, Life, and Property and Casualty.

Heading:
Pos Id Segment Name Req Max Use Repeat Notes Usage
010 ST Transaction Set Header M 1
020 BHT Beginning of Hierarchical Transaction M 1
Detail:
Pos Id Segment Name Req Max Use Repeat Notes Usage
Loop ID - 2000A >1
010 HL Information Source Level M 1
Loop ID - 2100A 1
030 NM1 Information Source Name M 1
Loop ID - 2000B >1
010 HL Information Receiver Level M 1
Loop ID - 2100B 1
030 NM1 Information Receiver Name M 1
040 REF Information Receiver Additional Identification O 9
060 N3 Information Receiver Address O 1
070 N4 Information Receiver City/State/ZIP Code O 1
080 PER Information Receiver Contact Information O 3
090 PRV Information Receiver Provider Information O 1
Loop ID - 2000C >1
010 HL Subscriber Level M 1
020 TRN Subscriber Trace Number O 2 N2/020
Loop ID - 2100C 1
030 NM1 Subscriber Name M 1
040 REF Subscriber Additional Identification O 9
060 N3 Subscriber Address O 1
070 N4 Subscriber City/State/ZIP Code O 1
090 PRV Provider Information O 1
100 DMG Subscriber Demographic Information O 1
110 INS Subscriber Relationship O 1
120 DTP Subscriber Date O 2
Loop ID - 2110C 99
130 EQ Subscriber Eligibility or Benefit Inquiry Information O 1
135 AMT Subscriber Spend Down Amount O 1
170 III Subscriber Eligibility or Benefit Additional Inquiry Information O 10
190 REF Subscriber Additional Information O 1
200 DTP Subscriber Eligibility/Benefit Date O 1
Loop ID - 2000D >1
010 HL Dependent Level O 1
020 TRN Dependent Trace Number O 2 N2/020
Loop ID - 2100D 1
030 NM1 Dependent Name M 1
040 REF Dependent Additional Identification O 9
060 N3 Dependent Address O 1
070 N4 Dependent City/State/ZIP Code O 1
090 PRV Provider Information O 1
100 DMG Dependent Demographic Information O 1
110 INS Dependent Relationship O 1
120 DTP Dependent Date O 2
Loop ID - 2110D 99
130 EQ Dependent Eligibility or Benefit Inquiry Information O 1
170 III Dependent Eligibility or Benefit Additional Inquiry Information O 10
190 REF Dependent Additional Information O 1
200 DTP Dependent Eligibility/Benefit Date O 1
210 SE Transaction Set Trailer M 1