270 Health Care Real-time
Eligibility Inquiry
Companion Guide
December 2010 – Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Introduction ..................................................................................................................... 5
Purpose .......................................................................................................................... 5
Search Options ............................................................................................................... 5
Data Usage..................................................................................................................... 5
Preferences and Conventions ......................................................................................... 7
Privacy and Security Protection ...................................................................................... 7
Testing Requirements ..................................................................................................... 7
ISA and GS Segments – 270 Transaction....................................................................... 8
Aetna .............................................................................................................................. 9
AARP-UnitedHealthcare Ins Co .................................................................................... 14
American Medical Security (AMS)................................................................................. 16
American Republic Insurance Company (ARIC) ........................................................... 20
Americhoice of New Jersey .......................................................................................... 23
Amerigroup ................................................................................................................... 26
Arizona Medicaid (AHCCCS) ........................................................................................ 28
California Blue Cross (WellPoint Health Network) ......................................................... 31
California Medicaid (Medi-Cal) ...................................................................................... 35
Cariten Healthcare ........................................................................................................ 38
CHAMPVA .................................................................................................................... 41
CIGNA .......................................................................................................................... 43
Colorado Anthem Blue Cross Blue Shield (W ellPoint Health Network) ......................... 46
Connecticut Anthem Blue Cross Blue Shield (W ellPoint Health Network) ..................... 49
ConnectiCare ................................................................................................................ 52
CoreSource (AZ & MN) ................................................................................................. 55
Coventry Health Care ................................................................................................... 58
Diamond Plan (MD Medicaid) ....................................................................................... 62
Fidelis (CenterCare) ..................................................................................................... 66
First Ameritas of New York ........................................................................................... 69
First Health ................................................................................................................... 72
First Health (Mail Handlers) .......................................................................................... 76
Florida Blue Cross Blue Shield ..................................................................................... 80
Florida Medicaid ........................................................................................................... 83
Georgia Anthem Blue Cross Blue Shield (W ellPoint Health Network) ........................... 86
Government Employees Hospital Association (GEHA) ................................................. 89
Health Net of Arizona .................................................................................................... 92
Health Net of the Northeast .......................................................................................... 94
HealthPartners of Minnesota......................................................................................... 96
Humana ........................................................................................................................ 99
Illinois Blue Cross Blue Shield .................................................................................... 102
Illinois Medicaid .......................................................................................................... 105
Indiana Anthem Blue Cross Blue Shield (W ellPoint Health Network) .......................... 108
Indiana Medicaid......................................................................................................... 111
John Alden Life Insurance Company .......................................................................... 114
Kaiser Foundation Health Plan of Ohio ....................................................................... 117
Kentucky Anthem Blue Cross Blue Shield (W ellPoint Health Network) ....................... 119
Louisiana Blue Cross Blue Shield ............................................................................... 122
Louisiana Medicaid ..................................................................................................... 124
Maine Anthem Blue Cross Blue Shield (W ellPoint Health Network) ............................ 127
MAHP/MAMSI ............................................................................................................ 130
Massachusetts Blue Cross Blue Shield ....................................................................... 132
Massachusetts Medicaid ............................................................................................. 136
Medica Health Plans ................................................................................................... 139
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Tel: 719-277-7545 Fax: 719-277-0254
Medical Mutual of Ohio ............................................................................................... 143
Medicare – Applies to all states and the 10 U.S. Territories. ....................................... 146
Mega Life and Health Insurance ................................................................................. 148
Mega Life (TransAmerica Life) .................................................................................... 151
Missouri Anthem Blue Cross Blue Shield (W ellPoint Health Network)......................... 154
Missouri Medicaid ....................................................................................................... 157
Mutual of Omaha ........................................................................................................ 160
National Association of Letter Carriers (NALC) ........................................................... 163
New Hampshire Anthem Blue Cross Blue Shield (WellPoint Health Network)............. 166
New Jersey Blue Cross Blue Shield (Horizon) ............................................................ 169
New Jersey Medicaid .................................................................................................. 172
New Mexico Medicaid ................................................................................................. 175
New York Blue Cross Blue Shield (Empire) ................................................................ 177
New York Medicaid ..................................................................................................... 180
Nevada Anthem Blue Cross Blue Shield (W ellPoint Health Network).......................... 183
Nevada Medicaid ........................................................................................................ 186
Nippon Life (Principal Financial Group) ....................................................................... 189
North Carolina Medicaid ............................................................................................. 192
Ohio Anthem Blue Cross Blue Shield (W ellPoint Health Network) .............................. 194
Ohio Medicaid ............................................................................................................. 197
Oklahoma Medicaid .................................................................................................... 199
Oxford Health Plans .................................................................................................... 201
Pennsylvania Blue Cross Blue Shield (Highmark) ....................................................... 204
PacifiCare of California (HMO).................................................................................... 208
Pennsylvania Medicaid ............................................................................................... 211
Principal Financial Group (Principal Life) .................................................................... 214
QualChoice ................................................................................................................. 217
Texas Blue Cross Blue Shield..................................................................................... 220
Texas Medicaid........................................................................................................... 222
Three Rivers Health Plan ............................................................................................ 224
Three Rivers Health Plan / Unison MedPLUS (Medicaid) ........................................... 227
TRICARE (Champus) ................................................................................................. 230
Tufts Health Plan ........................................................................................................ 233
UMR W ausau ............................................................................................................. 235
UniCare (W ellPoint Health Network) ........................................................................... 238
UnitedHealthcare ........................................................................................................ 241
Virginia Anthem Blue Cross Blue Shield (W ellPoint Health Network) .......................... 245
Virginia Medicaid ........................................................................................................ 248
WEA Trust .................................................................................................................. 250
Wisconsin Anthem Blue Cross Blue Shield (W ellPoint Health Network)...................... 252
Wisconsin Medicaid .................................................................................................... 256
Wyoming Medicaid ..................................................................................................... 259
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Tel: 719-277-7545 Fax: 719-277-0254
Introduction
Ingenix Connectivity Solutions (ICS) is publishing this Electronic Data Interchange (EDI) 270/271
Eligibility Benefit Inquiry and Response Companion Guide to accompany the Health Care
Eligibility Benefit Inquiry and Response Implementation Guide for the ANSI ACS X12 270/271
Transaction Set.
The Implementation Guide provides general information about EDI transmission, such as delimiters,
enveloping and related topics. This ICS Companion Guide will not duplicate these efforts.
HIPAA Implementation Guides are available through Washington Publishing, Inc. at:
http://www.wpc-edi.com/
Purpose
In order to submit a successful 270 transaction, this document has been created to provide the required
data elements and combinations for each payer. All the required data elements that must be sent in an
X12 transaction are not specifically addressed in this document. For additional required fields please
refer to the ANSI ASC X12 270 Version 004010 Health Care Eligibility Benefit Inquiry and Response
Implementation guide.
Search Options
The 270 transactions have the flexibility for allowing a variety of patient information. In the tables below
you will find that each payer has multiple Search Options that are defined. The data elements are then
listed in conjunction with the Loops and Segments that are required. Payer edits for specific fields are
also documented, i.e. fields that require numeric or alphanumeric elements.
Data element usage can be found in the Segment fields in the table below. Required - means that the
data element is required by the payer for every request. Optional / Situational - is based on the
payer’s search preferences in order to further assist in the member inquiry. Please keep in mind the
more information that can be provided, the more likely the information source will find a match in their
system.
Patients may be identified in either Loop 2100C or 2100D. If the Patient has a unique identifier, such
as a suffix, or has his/her unique ID number specific to him/her then that person should be considered
as the Subscriber. Only Loop 2100C must be sent for identification purposes.
If the payer does not assign a unique identifier, such as a suffix, or a unique ID number to the
Dependents of the Subscriber, then the Subscriber and Dependents must be identified in Loops 2100C
and 2100D.
Data Usage
There are two levels in which the 270 transactions are divided:
The Header Level contains the transactions structure information; i.e. ISA and GS segments.
The Detail Level contains specific insurer, insured, dependent and requestor information. There are
four different ways in which the segments are utilized. Each HL is assigned a number identifying its
purpose.
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Loop 2000A – Information Source - Contains Insurer/ Payer Information.
ICS Payer ID should be used to properly route requests to the payer. For the current payers list, go to
www.enshealth.com and click on Payer Lists and select Real-time Eligibility Payer List.
Loop 2000B – Information Receiver – Contains Medical Service Provider Information
This is where the Submitters will identify them self to the payer by using either their assigned Provider
Identifier from the payer or Federal Tax ID Number.
Loop 2000C – Insured / Subscriber Information
This loop is used to identify the Insured Member/Subscriber data elements. Only Loop 2100C must be
sent for identification if the Patient has a unique identifier, such as a suffix, or has his/her unique ID
number specific to him/her.
Required data elements within Loop 2100C to generate a response if the patient is in their database
are as follows:
Patient’s Member ID
Patient’s First Name
Patient’s Last Name
Patient’s Birth Date
Loop 2000D – Dependent Information.
This loop is used to identify Dependent data elements. If the payer does not assign a unique identifier,
such as a suffix, or a unique ID number to the Dependents of the Subscriber, then the Subscriber and
Dependents must be identified in Loops 2100C and 2100D.
Required data elements within Loop 2100D to generate a response if the patient is in their database
are as follows:
Loop 2100C - Subscriber’s Member ID
Loop 2100D
Patient’s First Name
Patient’s Last Name
Patient’s Birth Date
Service Type Codes
In the EQ segment, a generic Service Type Code of “30”, Health Benefit Plan Coverage, must be
supported for Eligibility request by all payers. This is a requirement for HIPAA Compliance. If a payer
supports specific and/or additional service type codes, it will be listed in the EQ segment of that payer’s
specifications.
Eligibility or Benefit Inquiry Information
The following applies to both the Subscriber loop 2110C and Dependent loop 2110D:
If EQ01 is received and EQ02 is not received - EQ01 is passed.
If EQ02 is received and EQ01 is not received - EQ02 is passed.
If both EQ01 and EQ02 are received - EQ01 is passed.
If neither EQ01 nor EQ02 are received - EQ01 defaults to “30”.
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Preferences and Conventions
1. Trading Partner or Contractual Agreements specify the terms and conditions by which transactions
are exchanged electronically with ICS. This Companion Guide may be an addendum to a new or
existing Trading Partner or Contractual Agreement.
2. It is recommended in the Implementation Guide that each transaction be limited to 1 request per file
and ICS agrees with this limitation. Batch request are not supported by ICS at this time.
3. While ICS supports all of the characters in the extended character set, it is recommended that
incoming 270 data use the basic character set as defined in Appendix A of the Implementation Guide.
4. The Subscriber Hierarchical Level (HL segment) must be in order from one, in increments of one
(+1), and must be numeric.
5. Trading Partners cannot send test and production information within the same transaction file,
regardless of the transaction. Test data and production data must be submitted in separate files.
6. Only multiple data loops or segments should be populated with the first occurrence, and each loop
or segment populated consecutively thereafter. There should be no loops or segments without data.
7. Delimiters must be consistently applied throughout the transmissions. Any delimiter can be used as
long as the same one is used throughout the transmission. Printable characters are preferred.
Delimiters that are chosen should not be contained within the data.
Privacy and Security Protection
ICS will comply with the privacy and confidentiality requirements as outlined in the HIPAA Privacy and
Security regulations regarding the need to protect health information. All Trading Partners are also
expected to comply with these regulations.
Testing Requirements
ICS has adopted the Workgroup for Electronic Data Interchange (WEDI) Strategic National
Implementation Process (SNIP) Testing Sub-Workgroups recommendations on the types of testing that
needs to occur in order to remain in line with the health care industry’s testing recommendations. ICS
has selected Claredi for HIPAA transaction validation, compliance and testing. Initially, the types of
testing that ICS strongly recommends for the 270 Transaction Set includes:




Type 1: EDI syntax integrity testing – Testing of the EDI file for valid segments, segment order,
element attributes, testing for numeric values in numeric data elements, validation of X12 or
NCPDP syntax, and compliance with X12 and NCPDP rules. This will validate the basic
syntactical integrity of the EDI submission.
Type 2: HIPAA syntactical requirement testing – Testing for HIPAA Implementation Guidespecific syntax requirements, such as limits on repeat counts, used and not used qualifiers,
codes, elements and segments. Also included in this type is testing for HIPAA required or intrasegment situational data elements, testing for non-medical code sets as laid out in the
Implementation
Guide, and values and codes noted in the Implementation Guide via and X12 code list or table.
Type 3: Balancing – Test the transaction for balanced field totals, financial balancing of claims
or remittance advice, and balancing of summary fields, if appropriate. An example of this
includes items such as all claim line item amounts equal to the total claim amount.
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ISA and GS Segments – 270 Transaction
The following table details segment specifics and data elements that require specific information for ICS
processing.
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Interchange Control Header
ISA Interchange Control
ISA05 – Interchange
Header
ID Qualifier
ZZ
REQUIRED
REQUIRED
ISA06 – Interchange
Sender ID
ISA07 – Interchange
ID Qualifier
ISA08 – Interchange
Receiver ID
GS Functional Group
Header
GS02 – Application
Sender’s Code
REQUIRED
REQUIRED
ICS User ID – preferred: or,
Sender’s Tax ID
ZZ
841162764
ICS Tax ID – 841162764
ICS User ID – preferred: or,
Sender’s Tax ID
REQUIRED
GS03 – Application
Receiver’s Code
Page 8 of 259
841162764
ICS Tax ID – 841162764
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Tel: 719-277-7545 Fax: 719-277-0254
Aetna
Search Options
Code
*1
*2
*3
*4
*5
*6
*7
*8
Search
Option
Subscriber 1
HMO
Subscriber 2
Non-HMO
Subscriber 3
Non-HMO
Subscriber 4
Non-HMO
Subscriber or
Dependent 5
Dependent 1
Non-HMO
Dependent 2
Non-HMO
Dependent 3
Non-HMO
Field 1
Search
Subscriber
Member ID
Subscriber
Member ID
Subscriber
SSN
Subscriber
Employee ID
Subscriber
Last Name
Subscriber
Member ID
Subscriber
Employee ID
Subscriber
SSN
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Subscriber
DOB
Subscriber
DOB
Subscriber
DOB
Subscriber Subscriber Patient
Patient
Patient
First Name
DOB
Last Name First Name DOB
Patient
DOB
Patient
DOB
Patient
DOB
Payer Name
Payer Name
Aetna
Payer ID
60054
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
NM101 - Entity
Identifier Code
PR
Payer
NM1 Information Source
Name
NM102 – Entity Type
Qualifier
2
Non-Person Entity
REQUIRED
NM1 Information Source
Name
NM103 – Organization
Name
Aetna
Organization Name
REQUIRED
NM1 Information Source
Name
NM108 – Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
60054
Carrier ID
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
REQUIRED
NM1 Information Source
Name
REQUIRED
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Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific to
ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Entity Identifier
Code
NM101 - Entity
Identifier Code
1P
Provider
NM108 – Identification
Code Qualifier
SV
Service Provider Identification
REQUIRED
NM1 Information
Receiver Provider PIN,
PVN or Organization
Number
SITUATIONAL
NM1 Information
Receiver Provider PIN,
PVN or Organization
Number
One of the following is required: PIN,
PVN, Federal Tax ID or NPI
* PIN should be 7-10 characters.
* PVN should be 2-7 characters
(AN).
NM109 – Identification
Code
SITUATIONAL
NM1 Information
Receiver Provider Tax ID
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Provider Tax ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information
Receiver Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Provider NPI
NM109 – Identification
Code
Service Provider Identification
* PIN should be 7-10 characters.
* PVN should be 2-7 characters
(AN).
FI
Federal Tax ID Number
One of the following is required: PIN,
PVN, Federal Tax ID or NPI
Federal Tax ID Number
XX
National Provider Identifier (NPI)
One of the following is required: PIN,
PVN, Federal Tax ID or NPI
National Provider Identifier (NPI)
SEE NOTE BELOW REGARDING
THE PROVIDER’S NPI
SITUATIONAL
REF Information
Receiver Provider
REF01 – Reference
Identification Qualifier
OPTIONAL
REF Information
Receiver Provider
Carrier Assigned Reference
Number. The Carrier Assigned
Reference Number of the provider is
optional as a 2ndary identifier in the
REF segment of this loop.
REF02 – Reference
Identification
Carrier Assigned Reference
Number. The Carrier Assigned
Reference Number of the provider is
optional as a 2ndary identifier in the
REF segment of this loop.
OPTIONAL
NOTE:
* Prior to sending a RT Eligibility Request to Aetna, the Provider NPI must have been previously entered into the
Aetna System. Aetna individual participating Providers and Hospitals can confirm that their NPI is in this system at:
http://www.aetna.com/docfind/DocFind?this_page=enter_welcome.jsp&site_id=provider
* If the NPI is not located in Aetna’s System, the Provider can share their NPI with Aetna at:
http://www.aetna.com/provider/medical/npi_med/index.html
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Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific to
ICS
Designator(s)
Loop 2100C
NM Subscriber Member
ID
NM108 – Identification
Code Qualifier
*1, *2, *6
NM Subscriber Member
ID
NM109 – Identification
Code
*1, *2, *6
NM Subscriber Last
Name
NM103 – Subscriber
Last Name
MI
Subscriber Member ID
Subscriber Member ID; if not W-ID,
SSN or Employee ID
*5
NM Subscriber First
Name
NM104 – Subscriber
First name
*5
DMG Subscriber DOB
DMG02 – Date/Time
Period
CCYYMMDD
Subscriber DOB
REF01 – Reference
Identification Code
Qualifier
SY
Subscriber SSN
*2, *3, *4, *5
REF Subscriber SSN
*3, *8
REF Subscriber SSN
REF02 – Reference
Identification
Subscriber SSN
*3, *8
REF Subscriber
Employee ID
REF01 – Reference
Identification Code
Qualifier
A6
Subscriber Employee ID
*4, *7
REF Subscriber
Employee ID
REF02 – Reference
Identification
Subscriber Employee ID
*4, *7
SITUATIONAL
REF01 – Reference
Identification Code
Qualifier
REF Subscriber Group
Number
REF02 – Reference
Identification
REF Subscriber Group
Number
SITUATIONAL
REF Subscriber Patient
Account Number
SITUATIONAL
REF Subscriber Patient
Account Number
REF01 – Reference
Identification Code
Qualifier
REF02 – Reference
Identification
6P
Subscriber Group Number
Subscriber Group Number
EJ
Patient Account Number
Patient Account Number
SITUATIONAL
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INS Subscriber
Relationship
OPTIONAL
INS Subscriber
Relationship
INS01 – Yes/No
Condition or Response
Code
Y = Yes
Subscriber Relationship
INS02 – Reference
Identification
18 = Self
Subscriber Relationship
DTP01 – Date/Time
Qualifier
472
Service Date
DTP02 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
OPTIONAL
DTP Service Date
REQUIRED
DTP Service Date
REQUIRED
DTP Service Date
REQUIRED
Loop 2110C
EQ Service Type Code
EQ01 - Service Type
Code
OPTIONAL
EQ Service Type Code
OPTIONAL
EQ Service Type Code
EQ02-1 –
Product/Service ID
Qualifier
AD = American Dental
Association Codes
EQ03 – Benefit
Coverage Level Code
FAM = Family
DTP01 – Date Time
Qualifier
472
DTP02 – Date Time
Period Format
Qualifier
DTP03 – Date Time
Period
D8
CCYYMMDD
OPTIONAL
DTP Service Date
OPTIONAL
DTP Service Date
OPTIONAL
DTP Service Date
CCYYMMDD
Service Date
Service Type Code
The following codes are not used
by Aetna:
14, 23, 24, 25, 26, 27, 28, 36, 38,
39, 41
Product/Service ID
The following codes are not used
by Aetna:
CJ, HC, ID, IV, N4, ZZ
Benefit Coverage Level Code
The following codes are not used
by Aetna:
CHD, DEP, ECH, EMP, ESP,
IND, SPC, SPO
Service Date
Service Date
OPTIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific to
ICS
Designator(s)
Loop 2100D
NM Dependent Last
Name
NM103 – Last Name
Patient Last Name
*5
NM Dependent First
Name
NM104 – First Name
Patient First Name
*5
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DMG01 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
Patient Birth Date
*6, *7, *8
NM Dependent Birth
Date
DMG02 – Dependent
Birth Date
CCYYMMDD
Patient Birth Date
*6, *7, *8
REF Dependent Group
Number
REF01 – Reference
Identification Qualifier
6P
Patient Group Number
NM Dependent Birth
Date
OPTIONAL
REF Dependent Group
Number
REF02 – Reference
Identification
Patient Group Number
OPTIONAL
REF Dependent Patient
Account Number
REF01 – Reference
Identification Qualifier
EJ
Patient Account Number
OPTIONAL
REF Dependent Patient
Account Number
REF02 – Reference
Identification
Patient Account Number
OPTIONAL
DTP Service Date
REQUIRED
DTP Service Date
REQUIRED
DTP Service Date
REQUIRED
Loop 2110D
EQ - Service Type Code
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
DTP03 – Eligibility
Start Date
CCYYMMDD
EQ01- Service Type
Code
OPTIONAL
EQ Service Type Code
OPTIONAL
DTP Service Date
OPTIONAL
DTP Service Date
OPTIONAL
DTP Service Date
EQ02-1 –
Product/Service ID
Qualifier
AD = American Dental
Association Codes
DTP01 – Date Time
Qualifier
472
DTP02 – Date Time
Period Format
Qualifier
D8
CCYYMMDD
DTP03 – Date Time
Period
CCYYMMDD
Service Date
Service Date
Service Type Code
The following codes are not used
by Aetna:
14, 23, 24, 25, 26, 27, 28, 36, 38,
39, 41
Product/Service ID
The following codes are not used
by Aetna:
CJ, HC, ID, IV, N4, ZZ
Service Date
Service Date
OPTIONAL
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AARP-UnitedHealthcare Ins Co
Search Options
Code
Search
Option
*1
Subscriber
Field 1
Search
Subscriber
Member ID
Field 2
Search
Subscriber
Last Name
Field 3
Search
Subscriber
First Name
Payer Name
Payer Name
AARP-UnitedHealthcare Ins Co
Payer ID ^
36273
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
Reference
Designator(s)
Value
Definitions and Notes Specific
to ICS
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
36273
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
Designator(s)
to ICS
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Entity Identifier
Qualifier
Code
REQUIRED
NM1 Information
NM108 – Identification FI
Service Provider Tax ID
Receiver Service
Code Qualifier
Provider Tax ID
REQUIRED
NM1 Information
NM109 – Identification
Service Provider Tax ID
Receiver Service
Code
Provider Tax ID
*1
REQUIRED
Page 14 of 259
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Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Designator(s)
Value
Definitions and Notes Specific
to ICS
Loop 2100C
NM1 Subscriber Last
Name
NM103 – Subscriber
Last Name
Subscriber Last Name
NM104 – Subscriber
First Name
Subscriber First Name
*1
REQUIRED
NM1 Subscriber First
Name
*1
REQUIRED
NM1 Subscriber Member
ID
REQUIRED
NM1 Subscriber Member
ID
NM108 – Identification
Code Qualifier
MI
NM109 – Identification
Code
MI = Subscriber Member ID
Subscriber Member ID
*1
REQUIRED
DTP Service Start Date
DTP03 – Service Start
Date
CCYYMMDD
DTP03 – Date/Time
Period Format
Qualifier
CCYYMMDD
OPTIONAL
DTP Service End Date
OPTIONAL
Service End Date

6 - 8 positions (4 digit year, 1 or 2 position month, 1 or 2 position day). If no date is supplied, the process will default the date to the current
date. If a date is supplied it must fall either prior to or within the current month. No future dates beyond the current month will be accepted.

6 - 8 positions (4 digit year, 1 or 2 position month, 1 or 2 position day). If no date is supplied, the process will default the date to the current
date. If a date is supplied it must fall either prior to or within the current month. No future dates beyond the current month will be accepted.
Page 15 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
American Medical Security (AMS)
Search Options
Search
Option
Code
*1
*2
Subscriber
Dependent
Field 1
Search
Subscriber
Member ID
Subscriber
Member ID
Field 2
Search
Subscriber
Last Name
Subscriber
Last Name
Field 3
Search
Subscriber
First Name
Dependent
Last Name
Field 4
Search
Subscriber
Birth Date
Dependent
First Name
Field 3
Search
Service
Date
Dependent
Birth Date
Field 4
Search
Service
Date
Payer Name
Payer Name
American Medical Security (AMS)
Payer ID ^
81400
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
81400
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Provider Last
Name or Organization
Name
NM101 - Entity
Identifier Code
1P
Provider
NM102 – Entity Type
Qualifier
1
Person
NM103 – Provider Last
Name or Organization
Name
REQUIRED
Page 16 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Provider First
Name
NM104 – Provider
First Name
REQUIRED
NM1 Information
Receiver Service
Provider Tax ID
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider Tax ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF02 – Identification
Code
FI
Service Provider Tax ID
Service Provider Tax ID
XX
Service Provider NPI
Service Provider NPI
TJ
Service Provider Tax ID
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member
ID
NM108 – Identification
Code Qualifier
REQUIRED
NM Subscriber Member
ID
NM109 – Identification
Code
REQUIRED
NM1 Subscriber Last
Name
NM103 – Subscriber
Last Name
*1, *2
NM1 Subscriber First
Name
NM104 – Subscriber
First Name
*1
DMG Subscriber Birth
Date
*1
Page 17 of 259
DMG02 – Subscriber
Birth Date
MI
CCYYMMDD
Subscriber Birth Date
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Service Start Date
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
EQ01- Service Type
Code
30
Service Start Date
*1
DTP Service Start Date
*1
DTP Service Start Date
*1
Service Start Date
Loop 2110C
EQ - Service Type
Code
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM Dependent Last
Name
NM103 – Dependent
Last Name
*2
NM Dependent First
Name
NM104 – Dependent
First Name
*2
DMG Dependent Birth
Date
DMG02 – Dependent
Birth Date
CCYYMMDD
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
EQ01- Service Type
Code
30
*2
DTP Service Start Date
*2
DTP Service Start Date
*2
DTP Service Start Date
*2
Loop 2110D
EQ - Service Type
Code
Dependent Birth Date
SITUATIONAL
Page 18 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
AMS Payer Batch Responses should be retrieved via the ICS Message Center in one business day.
Sample Request For Retrieving 271 Message Content
<?xml version="1.0" encoding="UTF-8" ?>
- <request>
- <transaction-set type="notification">
- <notification action="select">
<company-id />
<content-format />
<sender />
<urgent />
<content-type />
<timestamp />
<subject />
<user-id />
<organization-id />
<id />
<read />
<content />
- <condition operator="and">
- <condition operator="or">
- <condition operator="greater-than">
<timestamp>10-01-2006</timestamp>
</condition>
- <condition operator="equal">
<timestamp>10-01-2006</timestamp>
</condition>
</condition>
- <condition operator="like">
<subject>%AMS%</subject>
</condition>
- <condition operator="equal">
<read>N</read>
</condition>
- <condition operator="equal">
<content-type>ELIGIBILITY</content-type>
</condition>
</condition>
</notification>
</transaction-set>
</request>
Page 19 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
American Republic Insurance Company (ARIC)
Search Options
Code
Search
Option
*1
Subscriber 1
*2
Dependent 1
Field
1 Search
Subscriber
Member ID
Subscriber
Member ID
Field
2 Search
Subscriber
Last Name
Dependent
Last Name
Field
3 Search
Subscriber
First Name
Dependent
First Name
Field
4 Search
Subscriber
DOB
Dependent
DOB
Payer Name
Payer Name
American Republic Insurance
Payer ID ^
41099
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
NM101 - Entity
Identifier Code
PR
Payer
REQUIRED
NM1 Information Source
Name
NM102 – Entity Type
Qualifier
2
Non-Person Entity
REQUIRED
NM1 Information Source
Name
NM108 – Identification
Code Qualifier
PI
Payer Identification
REQUIRED
NM1 Information Source
Name
NM109 - Identification
Code
41099
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
NM101 - Entity
Identifier Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
Designator(s)
Loop 2100B
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
Page 20 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Federal Tax ID
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Federal Tax ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
FI
Federal Tax ID Number Qualifier
Federal Tax ID Number
NOTE: Either tax ID or NPI is
required.
XX
Service Provider NPI
Service Provider NPI
NOTE: Either tax ID or NPI is
required.
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member
ID
NM108 – Identification
Code Qualifier
REQUIRED
NM Subscriber Member
ID
NM109 – Identification
Code
REQUIRED
NM1 Subscriber Last
Name
NM103 – Subscriber
Last Name
*1
NM1 Subscriber First
Name
NM104 – Subscriber
First Name
*1
DMG Subscriber Birth
Date
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date
*1
REF Subscriber Group
Number
REF01 – Reference
Identification Qualifier
6P
Group Number Qualifier
OPTIONAL
REF Subscriber Group
Number
REF02 – Reference
Identification
OPTIONAL
DTP Service Start Date
OPTIONAL
DTP Service Start Date
OPTIONAL
Page 21 of 259
MI
Group Number
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
Service Start Date Qualifier
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Service Start Date
DTP03 – Service Start
Date
CCYYMMDD
Service Start Date Required.
EQ01- Service Type
Code
30
Required for Subscriber
search.
OPTIONAL
Loop 2110C
EQ - Service Type
Code
REQUIRED
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM Dependent Last
Name
NM103 – Dependent
Last Name
*2
NM Dependent First
Name
NM104 – Dependent
First Name
*2
NM Dependent Birth
Date
DMG02 – Dependent
Birth Date
CCYYMMDD
Dependent Birth Date
*2
REF Dependent Group
Number
REF01 – Reference
Identification Qualifier
6P
Group Number Qualifier
OPTIONAL
REF Dependent Group
Number
REF02 – Reference
Identification
OPTIONAL
DTP Service Start Date
OPTIONAL
DTP Service Start Date
OPTIONAL
DTP Service Start Date
OPTIONAL
Loop 2110D
EQ - Service Type
Code
Group Number
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
Service Start Date
EQ01- Service Type
Code
30
Required for Dependent
search.
Service Start Date Qualifier
REQUIRED
Page 22 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Americhoice of New Jersey
Search Options
Search
Option
Code
*1
Subscriber 1
*2
Subscriber 2
*3
Subscriber 3
*4
Subscriber 4
Field 1
Search
Subscriber
Member ID
Subscriber
SSN
Subscriber
SSN
Subscriber
Member ID
Field 2
Search
Service Start
Date
Subscriber
Birth Date
Subscriber
Last Name
Subscriber
Last Name
Field 3
Search
Field 4
Search
Field 5
Search
Service Start
Date
Subscriber
First Name
Subscriber
First Name
Service Start
Date
Subscriber
Birth Date
Service Start
Date
Payer Name
Payer Name
Americhoice of New Jersey
Payer ID ^
86047
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
NM101 - Entity
Identifier Code
PR
Payer
NM1 Information Source
Name
NM102 – Entity Type
Qualifier
2
Non-Person Entity
REQUIRED
NM1 Information Source
Name
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
86047
Carrier ID
REQUIRED
REQUIRED
NM1 Information Source
Name
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
1P
Provider
Designator(s)
Loop 2100B
NM1 Information
Receiver Entity Identifier
Code
NM101 - Entity
Identifier Code
REQUIRED
Page 23 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Service
Provider ID
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification
Code Qualifier
FI
34
Federal Tax ID
SSN
REQUIRED
NM1 Information
Receiver Provider ID
NM109 – Identification
Code
REQUIRED
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
Either Federal Tax ID or SSN is
required.
XX
Service Provider NPI
Service Provider NPI
TJ
REF02 – Tax ID
Identification Code
Service Provider Tax ID
Service Provider Tax ID
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
MI
Subscriber Member ID
Designator(s)
Loop 2100C
NM1 Subscriber Member
ID
NM108 – Identification
Code Qualifier
*1 and *4
SITUATIONAL
NM1 Subscriber Member
ID
NM109 – Identification
Code
Subscriber Member ID
*1 and *4
SITUATIONAL
NM1 Subscriber Last
Name
*3 and *4
NM103 – Subscriber
Last Name
SITUATIONAL
NM1 Subscriber First
Name
NM104 – Subscriber
First Name
*3 and *4
SITUATIONAL
Page 24 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DMG Subscriber Birth
Date
DMG02 – Subscriber
Birth Date
CCYYMMDD
REF01 – Subscriber
SSN
SY
*2 and *4
SITUATIONAL
REF – Subscriber SSN
*2 and *3
SITUATIONAL
REF02 – Subscriber
SSN
REF – Subscriber ID
Card Serial Number
REF01 – Subscriber
ID Card Serial Number
GH
Card Serial Number is only
required if card swipe is used.
REF – Subscriber
REF02 – Subscriber
ID Card Serial Number
38
Card Serial Number is only
required if card swipe is used.
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Service Start
Date
D8
EQ01- Service Type
Code
30
SITUATIONAL
DTP Service Start date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
CCYYMMDD
REQUIRED
Cannot be more than 1 year
prior to current date and no
more than 1 year in the future.
Loop 2110C
EQ - Service Type
Code
REQUIRED
Page 25 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Amerigroup
Payer Name
Payer Name
Amerigroup
Payer ID ^
28806
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM101 - Entity
Identifier Code
PR
Payer
NM1 Information Source
Name
NM102 – Entity Type
Qualifier
2
Non-Person Entity
REQUIRED
NM1 Information Source
Name
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
28806
Carrier ID
REQUIRED
NM1 Information Source
Name
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Service
Provider ID
REQUIRED
NM1 Information
Receiver Provider ID
NM101 - Entity
Identifier Code
1P
Provider
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification
Code Qualifier
FI
Federal Tax ID
NM109 – Identification
Code
NOTE: Payer will only accept
Federal Taxpayer’s ID
Federal Tax ID
REQUIRED
Page 26 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM108 – Identification
Code Qualifier
NM1 Information
Receiver Service
Provider NPI
NOT USED
NM1 Information
Receiver Service
Provider NPI
XX
Service Provider NPI
NOTE: Payer will only accept
Federal Taxpayer’s ID
NM109 – Identification
Code
Service Provider NPI
NOT USED
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
MI
Subscriber Member ID
Designator(s)
Loop 2100C
NM1 Subscriber Member
ID
NM108 – Identification
Code Qualifier
REQUIRED
NM1 Subscriber Member
ID
NM109 – Identification
Code
Subscriber Member ID
REQUIRED
NM1 Subscriber Last
Name
NM103 – Subscriber
Last Name
REQUIRED
NM1 Subscriber First
Name
NM104 – Subscriber
First Name
REQUIRED
DMG Subscriber Birth
Date
DMG02 – Subscriber
Birth Date
CCYYMMDD
REF01 –Group
Number Qualifier
6P
REQUIRED
REF – Subscriber Group
Number
OPTIONAL
REF – Subscriber Group
Number
OPTIONAL
DTP Service Start date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REF02 – Subscriber
Group Number
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Service Start
Date
D8
EQ01- Service Type
Code
30
CCYYMMDD
REQUIRED
Loop 2110C
EQ - Service Type
Code
REQUIRED
Page 27 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Arizona Medicaid (AHCCCS)
Search Options
Search
Option
Code
*1
Subscriber 1
*2
Subscriber 2
*3
Subscriber 3
Subscriber 4
(card swipe)
*4
Field 1
Search
Subscriber
Member ID
Subscriber
SSN
Subscriber
Last Name
Subscriber
ID
Field 2 Search
Subscriber
First Name
Subscriber ID Card
Serial Number @
Field 3
Search
Field 4
Search
Subscriber
DOB
Subscriber
Gender
Payer Name
Payer Name
Arizona Medicaid (AHCCCS)
Payer ID ^
AZMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
AZMCD
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Name
REQUIRED
NM1 Information
Receiver Name
REQUIRED
NM1 Information
Receiver Service
Provider ID
NM101 - Entity
Identifier Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
SV
Service Provider Number Receiver ID assigned by the
payer to the provider Service
Provider Number
SITUATIONAL
Page 28 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM109 – Identification
Code
NM1 Information
Receiver Service
Provider ID
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF02 – Identification
Code
Service Provider Number Receiver ID assigned by the
payer to the provider Service
Provider Number
XX
Service Provider NPI
Service Provider NPI
N5
Service Provider Number Receiver ID assigned by the
payer to the provider Service
Provider Number
Service Provider Number Receiver ID assigned by the
payer to the provider Service
Provider Number
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
MI
Member Identification Number
AHCCCS (Medicaid) ID
Designator(s)
Loop 2100C
NM1 Subscriber Last
Name
NM103 – Subscriber
Last Name
*3
NM1 Subscriber Member
ID
*1, *4
NM1 Subscriber ID
NM108 – Identification
Code Qualifier
NM109 – Identification
Code
AHCCCS (Medicaid) ID
*1, *4
REF Subscriber ID Card
Serial Number @
*4
REF Subscriber ID Card
Serial Number @
REF01 – Reference
Identification Qualifier
GH
Card Control Number is required
if card swipe is used
Identification Card Serial
Number
Card Control Number is required
if card swipe is used
REF02 – Reference
Identification
*4
REF Subscriber SSN
REF01 – Reference
Identification Qualifier
Identification Card Serial
Number
SY
Social Security Number
*2
Page 29 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Subscriber SSN
REF02 – Reference
Identification
*2
DMG Subscriber Birth
Date
DMG02 – Subscriber
Birth Date
CCMMYYDD
Subscriber Birth Date
DMG03 – Gender
Code
F = Female
M = Male
Subscriber Gender Code
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Format Qualifier
RD8
CCYYMMDD CCYYMMDD
Service Date Range
DTP03 – Service Start
Date
CCYYMMDD CCYYMMDD
Service Start Date
*3
DMG Subscriber Gender
*3
DTP Service Start Date
REQUIRED
DTP Service Start Date
Social Security Number
REQUIRED
DTP Service Start Date
REQUIRED
Cannot be more than 365 days
prior to current date or more
than 30 days in the future.
Span cannot exceed 365 days.
Loop 2110C
EQ - Service Type
Code
EQ01- Service Type
Code
REQUIRED
@Indicates that field data may be obtained from card swipe.
Page 30 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
California Blue Cross (WellPoint Health Network)
Search Options
Code
Search
Option
*1
Subscriber
*2
Dependent
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Subscriber
Last Name
Subscriber
Last Name
Subscriber
First Name
Subscriber
First Name
Subscriber
DOB
Subscriber
Member ID
Subscriber
Member ID
Dependent
Last Name
Subscriber
Gender
Dependent
First Name
Dependent
DOB
Dependent
Gender
Payer Name
Payer Name
California Blue Cross
Payer ID ^
00540
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
00540
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Entity Identifier
Code
NM101 - Entity
Identifier Code
1P
Provider
REQUIRED
NM1 Information
Receiver Entity Identifier
Code
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification
Code Qualifier
FI
Federal Tax ID
REQUIRED
NM1 Information
Receiver Federal Tax ID
REQUIRED
Page 31 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Federal Tax ID
NM109 – Identification
Code
REQUIRED
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF02 – Identification
Code
Federal Tax ID
XX
Service Provider NPI
Service Provider NPI
TJ
Service Provider Tax ID
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last
NM103 – Subscriber
Subscriber Last Name
Name
Last Name
Segment
REQUIRED
NM1 Subscriber First
Name
NM104 – Subscriber
First Name
REQUIRED
NM1 Subscriber Member
ID
NM108 – Identification
Code Qualifier
REQUIRED
NM1 Subscriber Member
ID
NM109 – Identification
Code
REQUIRED
DMG Subscriber Birth
Date
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date
Required if patient is Subscriber.
DMG03 – Gender
Code
F = Female
M = Male
Subscriber Gender Code
DTP01 – Date/Time
Qualifier
472
Service Start Date
*1
SITUATIONAL
DMG Subscriber Gender
*1
SITUATIONAL
DTP Service Start Date
REQUIRED
Page 32 of 259
Subscriber First Name
MI
Subscriber Member ID
Subscriber Member ID
Required if patient is Subscriber.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service End date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
DTP02 – Date/Time
Period Format Qualifier
D8
DTP03 – Service Start
Date
CCYYMMDD
Service Start Date
DTP01 – Date/Time
Qualifier
472
Service End Date
DTP02 – Date/Time
Period Format Qualifier
D8
DTP03 – Service End
Date
CCYYMMDD
Service End Date
OPTIONAL
Loop 2110C
EQ - Service Type
Code
EQ01- Service Type
Code
30
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last
Name
*2
SITUATIONAL
NM1 Dependent First
Name
NM103 – Dependent
Last Name
Required if patient is the
Dependent.
NM104 – Dependent
First Name
Required if patient is the
Dependent.
*2
SITUATIONAL
DMG Dependent Birth
Date
DMG02 – Dependent
Birth Date
CCYYMMDD
Required if patient is the
Dependent.
.
DMG03 – Gender
Code
F = Female
M = Male
Subscriber Gender Code
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
Service Start Date
.
DTP01 – Date/Time
Qualifier
472
Service Start Date
*2
SITUATIONAL
DMG Dependent
Gender
*2
SITUATIONAL
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service End Date
Required if patient is the
Dependent.
OPTIONAL
Page 33 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Service End Date
OPTIONAL
DTP Service End Date
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Service Start
Date
D8
EQ01- Service Type
Code
30
CCYYMMDD
Service End Date
OPTIONAL
Loop 2110D
EQ - Service Type
Code
SITUATIONAL
Page 34 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
California Medicaid (Medi-Cal)
Search Options
Code
Search Option
*1
Subscriber 1
Subscriber 2
@ (card swipe)
*2
Field 1 Search
Subscriber
ID Card Number
Subscriber
Member ID
Field 2 Search
Subscriber
ID Card Issue Date
Subscriber
ID Card Issue Date
Payer Name
Payer Name
California Medicaid (Medi-Cal)
Payer ID
CAMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
CAMCD
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Service
Provider ID
NM101 - Entity
Identifier Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
SV
Service Provider Number Receiver ID assigned by the
payer to the provider.
SITUATIONAL
Page 35 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM109 – Identification
Code
NM1 Information
Receiver Service
Provider ID
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver PIN
REF01 – Reference
Identification Qualifier
REQUIRED
REF Information
Receiver PIN
REF02 – Reference
Identification
Service Provider Number Receiver ID assigned by the
payer to the provider.
XX
Service Provider NPI
Service Provider NPI
4A
Information Receiver
Personal ID Number (PIN)
Information Receiver
Personal ID Number (PIN)
REQUIRED
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Member NM108 – Identification MI
Recipient ID
ID
Code Qualifier
Segment
*2
NM1 Subscriber Member
ID
NM109 – Identification
Code
*2
REF Subscriber ID
Card Serial Number @
REF01 – Reference
Identification Qualifier
*1
REF Subscriber ID
Card Serial Number @
REF02 – Reference
Identification Number
*1
DMG Subscriber Birth
Date
REQUIRED
DMG Subscriber Birth
Date
REQUIRED
DTP Subscriber Card
Issue Date
REQUIRED
*1, *2
DTP Subscriber Card
Issue Date
REQUIRED
*1, *2
Page 36 of 259
Recipient ID
HJ
Identity Card Number
Identity Card Number
DMG01 – Subscriber
Birth Date Qualifier
D8
DMG02 – Subscriber
Birth Date
CCMMYYDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
102
Card Issue Date
DTP02 – Date/Time
Period Format
Qualifier
D8
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Subscriber Card
Issue Date
REQUIRED
*1, *2
DTP Service Start Date
OPTIONAL
DTP Service Start Date
OPTIONAL
DTP Service Start Date
OPTIONAL
Loop 2110C
EQ - Service Type
Code
DTP03 – Date/Time
Period
CCYYMMDD
Card Issue Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Format Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
EQ01- Service Type
Code
30
Service Start Date
REQUIRED
@Indicates that field data may be obtained from card swipe.
Change “Information Receiver UPIN” to “Information Receiver Personal ID Number” 6/19/06^
Page 37 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Cariten Healthcare
Search Options
Code
Search
Option
Field 1
Search
*1
Patient
Member ID
Field 2
Search
Patient
First Name
Field 3
Search
Patient
Last Name
Field 4
Search
Patient
DOB
Field 5
Search
Date of
Service
Payer Name
Payer Name
Cariten Healthcare
Payer ID ^
62073
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
NM101 - Entity
Identifier Code
PR
Payer
REQUIRED
NM1 Information Source
Name
NM102 – Entity Type
Qualifier
2
Non-Person Entity
REQUIRED
NM1 Information Source
Name
NM108 – Identification
Code Qualifier
PI
Payer Identification
REQUIRED
NM1 Information Source
Name
NM109 - Identification
Code
62073
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Federal Tax ID
NM101 - Entity
Identifier Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
FI
Federal Tax ID
SITUATIONAL
Page 38 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Federal Tax ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
Federal Tax ID
XX
NOTE: If NPI is submitted in
NM109, send a REF02 =
Federal Tax ID.
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
Service Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF02 – Identification
Code
Service Provider NPI
TJ
Service Provider Tax ID
NOTE: If NPI is submitted in
NM109, send a REF02 =
Federal Tax ID.
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
Member ID
NM108 – Identification
Code Qualifier
REQUIRED
NM1 Subscriber
Member ID
NM109 – Identification
Code
REQUIRED
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
REQUIRED
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
REQUIRED
DMG Subscriber
Birth Date
DMG02 – Subscriber
Birth Date
CCMMYYDD
REQUIRED
REF Subscriber
Group Number
REF01 – Reference
Identification Qualifier
6P
OPTIONAL
REF Subscriber
Group Number
REF02 – Reference
Identification
MI
OPTIONAL
Page 39 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Format Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
EQ01- Service Type
Code
30
REQUIRED
Loop 2110C
EQ - Service Type
Code
REQUIRED
Page 40 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
CHAMPVA
Search Options Not Applicable.
Payer Name
Payer Name
CHAMPVA
Payer ID ^
84146
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier
Code
NM102 – Entity Type
Qualifier
PR
Payer
2
Non-Person Entity
NM108 – Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
84146
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
Page 41 of 259
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
FI
Federal Tax ID
NM109 – Identification
Code
NM108 – Identification
Code Qualifier
Federal Tax ID
XX
NM109 – Identification
Code
REF01 – Identification
Code Qualifier
REF02 – Identification
Code
Service Provider NPI
Service Provider NPI
TJ
Service Provider Tax ID
Service Provider Tax ID
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
Member ID
REQUIRED
NM1 Subscriber
Member ID
NM108 – Identification
Code Qualifier
MI
NM109 – Identification
Code
Subscriber Member ID
Subscriber Member ID
REQUIRED
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
REQUIRED
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
REQUIRED
DMG Subscriber
Birth Date
DMG02 – Subscriber
Birth Date
CCMMYYDD
Subscriber Birth Date
REF01 – Reference
Identification Qualifier
6P
Group Number
REQUIRED
REF Subscriber
Group Number
OPTIONAL
REF Subscriber
Group Number
OPTIONAL
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
Loop 2110C
EQ - Service Type Code
REF02 – Reference
Identification
Group Number
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Format Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
EQ01- Service Type
Code
30
Service Start Date
Service Start Date
REQUIRED
Page 42 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
CIGNA
Search Options
Search
Option
Code
*1
*2
Subscriber
Dependent
Field 1
Search
Subscriber
Member ID
Subscriber
Member ID
Field 2
Search
Subscriber
Last Name
Dependent
Last Name
Field 3
Search
Subscriber
First Name
Dependent
First Name
Field 4
Search
Subscriber
Birth Date
Dependent
Birth Date
Field 5
Search
Service
Date
Service
Date
Payer Name
Payer Name
CIGNA Healthcare
Payer ID
62308
Loop 2100A – Information Source Name
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier
Code
NM102 – Entity Type
Qualifier
NM108 – Identification
Code Qualifier
NM109 - Identification
Code
PR
Payer
2
Non-Person Entity
PI
Payer Identification
62308
Carrier ID
Loop 2100B – Information Receiver Name
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
NM101 - Entity Identifier
Code
1P
Provider
NM108 – Identification
Code Qualifier
FI
Federal Tax ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information Receiver
Service Provider Number
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider Number
NM109 – Identification
Code
Federal Tax ID
SV
Service Provider Number
SITUATIONAL
Page 43 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
XX
Service Provider NPI
Service Provider NPI
SITUATIONAL
Loop 2100C – Subscriber Name
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing
Segment
Reference
Value
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*1
NM1 Subscriber First Name
*1
NM Subscriber Member ID
*1, *2
REQUIRED
NM Subscriber Member ID
*1, *2
DMG Subscriber Birth Date
*1
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
NM103 – Subscriber
Last Name
NM104 – Subscriber
First Name
NM108 – Identification
Code Qualifier
MI
NM109 – Identification
Code
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
307, or 435, or 472
Service Start Date
DTP02 – Date/Time
Period Format Qualifier
D8, or RD8
DTP03 – Service Start
Date
CCYYMMDD
or
CCYYMMDD CCYYMMDD
*1
Loop 2110C
EQ - Service Type Code
Definitions and Notes Specific
to ICS
EQ01- Service Type
Code
OPTIONAL
Service Start Date
Default is code ‘30’
If Dental code ‘35’ is submitted,
Service Start Date must be
current date
Loop 2100D – Dependent Name
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM Dependent Last Name
NM103 – Dependent
Last Name
*2
Page 44 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM Dependent First Name
*2
NM Dependent Birth Date
*2
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
*2
Loop 2110D
EQ - Service Type Code
OPTIONAL
Page 45 of 259
NM104 – Dependent
First Name
DMG02 – Dependent
Birth Date
CCYYMMDD
Dependent Birth Date
DTP01 – Date/Time
Qualifier
307, or 435, or 472
Service Start Date
DTP02 – Date/Time
Period Format Qualifier
D8, or RD8
DTP03 – Service Start
Date
CCYYMMDD
or
CCYYMMDD CCYYMMDD
EQ01- Service Type
Code
Service Start Date
Default is code ‘30’
If Dental code ‘35’ is submitted,
Service Start Date must be
current date
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Colorado Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Code
Search
Option
*1
Subscriber
*2
Dependent
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Subscriber
Last
Name
Subscriber
Last
Name
Subscriber
First
Name
Subscriber
First
Name
Subscriber
DOB
Subscriber
Member
ID
Subscriber
Member ID
Subscriber
Gender
Dependent
Last Name
Dependent
First Name
Field 6
Search
Field 7
Search
Dependent
DOB
Dependent
Gender
Payer Name
Payer Name
Colorado Blue Cross Blue Shield
Payer ID ^
COBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Name
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Name
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
COBLS
Carrier ID
Name
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Service
Provider ID
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification
Code Qualifier
SV
XX
Provider ID
NPI
REQUIRED
Page 46 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM109 – Identification
Code
NM1 Information
Receiver Provider ID
REQUIRED
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF02 – Identification
Code
If NM108 is equal to S, segment
should be the Provider ID.
Q4
If NM108 is equal to XX,
segment should be the NPI.
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
Member ID
NM108 – Identification
Code Qualifier
REQUIRED
NM Subscriber
Member ID
NM109 – Identification
Code
Subscriber Member ID
NM103 – Subscriber
Last Name
Required for Subscriber Search.
NM104 – Subscriber
First Name
Required for Subscriber Search.
REQUIRED
NM1 Subscriber
Last Name
*1
SITUATIONAL
NM1 Subscriber
First Name
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Page 47 of 259
MI
Subscriber Member ID
DMG01 – Subscriber
Birth Date
D8
Required for Subscriber Search.
DMG02 – Subscriber
Birth Date
CCYYMMDD
Required for Subscriber Search.
DMG03 – Subscriber
Gender Code
M
F
Male
Female
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
CCYYMMDDCCYYMMDD
Range of dates in which the provider
is querying verification about a
patient’s eligibility. It is strongly
suggested that this field be
populated for certain identification of
the subscriber.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2110C
EQ - Service Type
Code
EQ01- Service Type
Code
30
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last
NM103 – Dependent
Required for Dependent Search.
Name
Last Name
*2
SITUATIONAL
NM1 Dependent First
Name
*2
SITUATIONAL
DMG Dependent Birth
Date
*2
SITUATIONAL
DMG Dependent Birth
Date
*2
SITUATIONAL
DMG Dependent Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
NM104 – Dependent
First Name
DMG01 – Dependent
Birth Date
Required for Dependent Search.
D8
Date expressed as
CCYYMMDD.
Required for Dependent Search.
DMG02 – Dependent
Birth Date
CCYYMMDD
Required for Dependent Search.
DMG02 – Dependent
Gender Code
M
F
Male
Female
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
EQ01- Service Type
Code
30
CCYYMMDDCCYYMMDD
OPTIONAL
Range of dates in which the provider
is querying verification about a
patient’s eligibility. It is strongly
suggested that this field be
populated for certain identification of
the subscriber.
Loop 2110D
EQ - Service Type
Code
SITUATIONAL
Page 48 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Connecticut Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Code
Search
Option
*1
Subscriber
*2
Dependent
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Subscriber
Last Name
Subscriber
Last Name
Subscriber
First Name
Subscriber
First Name
Subscriber
DOB
Subscriber
Member ID
Subscriber
Member ID
Dependent
Last Name
Subscriber
Gender
Dependent
First Name
Dependent
DOB
Dependent
Gender
Payer Name
Payer Name
Connecticut Blue Cross Blue Shield
Payer ID ^
CTBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
CTBLS
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Service
Provider ID
NM101 - Entity
Identifier Code
1P
Provider
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification
Code Qualifier
SV
XX
Provider ID
NPI
REQUIRED
Page 49 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Provider ID
NM109 – Identification
Code
REQUIRED
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF02 – Identification
Code
If NM108 is equal to S, segment
should be the Provider ID.
Q4
If NM108 is equal to XX,
segment should be the NPI.
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
Member ID
NM108 – Identification
Code Qualifier
REQUIRED
NM Subscriber
Member ID
NM109 – Identification
Code
Subscriber Member ID
NM103 – Subscriber
Last Name
Required for Subscriber Search.
NM104 – Subscriber
First Name
Required for Subscriber Search.
REQUIRED
NM1 Subscriber
Last Name
*1
SITUATIONAL
NM1 Subscriber
First Name
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Page 50 of 259
MI
Subscriber Member ID
DMG01 – Subscriber
Birth Date
D8
Required for Subscriber Search.
DMG02 – Subscriber
Birth Date
CCYYMMDD
Required for Subscriber Search.
DMG03 – Subscriber
Gender Code
M
F
Male
Female
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
CCYYMMDDCCYYMMDD
Range of dates in which the
provider is querying verification
about a patient’s eligibility. It is
strongly suggested that this field
be populated for certain
identification of the subscriber.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2110C
EQ - Service Type
Code
EQ01- Service Type
Code
30
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent
Last Name
*2
NM103 – Dependent
Last Name
Required for Dependent Search.
SITUATIONAL
NM1 Dependent
First Name
NM104 – Dependent
First Name
Required for Dependent Search.
*2
SITUATIONAL
DMG Dependent
Birth Date
DMG01 – Dependent
Birth Date
D8
Required for Dependent Search.
DMG02 – Dependent
Birth Date
CCYYMMDD
Required for Dependent Search.
DMG02 – Dependent
Gender Code
M
F
Male
Female
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
EQ01- Service Type
Code
30
*2
SITUATIONAL
DMG Dependent
Birth Date
*2
SITUATIONAL
DMG Dependent Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
Loop 2110D
EQ - Service Type
Code
Range of dates in which the
provider is querying verification
about a patient’s eligibility. It is
strongly suggested that this field
be populated for certain
identification of the subscriber.
SITUATIONAL
Page 51 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
ConnectiCare
Search Options
Code
Search
Option
*1
Subscriber
*2
Dependent
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Subscriber
Member ID
Subscriber
Member ID
Subscriber
Last Name
Dependent
Relation
Subscriber
First Name
Dependent
Last Name
Subscriber
DOB
Dependent
First Name
Service
Start Date
Dependent
DOB
Service
Start Date
Payer Name
Payer Name
ConnectiCare
Payer ID
06105
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
06105
Carrier ID
Payer ID
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Entity Identifier
Qualifier
Code
REQUIRED
NM1 Information
NM108 – Identification FI
Service Provider Tax ID
Receiver Service
Code Qualifier
Provider Tax ID
SITUATIONAL
NM1 Information
Receiver Service
Provider Tax ID
NM109 – Identification
Code
Service Provider Tax ID
SITUATIONAL
Page 52 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF02 – Identification
Code
XX
Service Provider NPI
Service Provider NPI
TJ
Service Provider Tax ID
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
*1
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
*1
NM1 Subscriber
Member ID
NM108 – Identification
Code Qualifier
REQUIRED
NM1 Subscriber
Member ID
NM109 – Identification
Code
REQUIRED
REF Subscriber
Group Number
REF01 – Reference
Identification Qualifier
OPTIONAL
REF Subscriber
Group Number
OPTIONAL
DMG Subscriber
Birth Date
*1
DTP Service Start Date
*1
DTP Service Start Date
*1
DTP Service Start Date
Page 53 of 259
MI
Subscriber Member ID
Subscriber Member ID
6P
REF02 – Reference
Identification
Group Number
Group Number
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date –
DTP02 – Date/Time
Format Qualifier
D8
DTP03 – Service Start
Date
CCYYMMDD
Required for Subscriber search
Service Start Date
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
*1
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110C
EQ - Service Type
Code
DTP01 – Date/Time
Qualifier
DTP02 – Date/Time
Format Qualifier
472
Service End Date
D8
Service End Date
DTP03 - Service End
Date
CCYYMMDD
Service End Date
EQ01- Service Type
Code
30
Required for Subscriber search.
OPTIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent
NM103 – Dependent
Dependent Last Name
Last Name
Last Name
*2
NM1 Dependent
First Name
NM104 – Dependent
First Name
*2
DMG Dependent
Birth Date
DMG02 – Dependent
Date of Birth
CCYYMMDD
*2
INS Individual
Relationship
INS02 – Individual
Relationship Code
01 = Spouse
19 = Child
34 = Other Adult
Required for Dependent search.
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Format Qualifier
D8
Service Start Date
DTP03 - Service Start
Date
CCYYMMDD
Required for Dependent search.
DTP01 – Date/Time
Qualifier
DTP02 – Date/Time
Format Qualifier
DTP03 - Service End
Date
472
Service End Date
D8
Service End Date
CCYYMMDD
Service End Date
EQ01- Service Type
Code
30
*2
DTP Service Start Date
*2
DTP Service Start Date
*2
DTP Service Start Date
*2
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110D
EQ - Service Type
Code
Dependent First Name
Required for Dependent search.
OPTIONAL
Page 54 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
CoreSource (AZ & MN)
Search Options
Code
Search Option
Field 1 Search
Field 2 Search
*1
Subscriber 1
Subscriber First Name
Subscriber Birth Date
*2
Dependent 1
Dependent First Name
Dependent Birth Date
Payer Name
Payer Name
CoreSource (AZ & MN)
Payer ID^
00234
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
00234
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Name
Identifier Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Name
Qualifier
REQUIRED
NM1 Information
NM108 – Identification FI
Federal Tax ID
Receiver Federal Tax ID
Code Qualifier
SITUATIONAL
NM1 Information
NM109 - Identification
Federal Tax ID
Receiver Federal Tax ID Code
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
XX
Service Provider NPI
SITUATIONAL
Page 55 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Service
Provider NPI
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
NM109 – Identification
Code
REF01 – Identification
Code Qualifier
Service Provider NPI
TJ
REF02 – Identification
Code
Service Provider Tax ID
Service Provider Tax ID
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
NM103 – Subscriber
Required for Subscriber
Last Name
Last Name
search.
REQUIRED
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
*1
NM1 Subscriber
Member ID
NM108 - Identification
Code Qualifier
REQUIRED
NM1 Subscriber
Member ID
NM109 - Identification
Code
REQUIRED
DMG Subscriber
Birth Date
DMG02 - Subscriber
Birth Date
CCYMMDD
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time
Format Qualifier
D8
DTP03 - Eligibility
Start Date
CCYYMMDD
Eligibility Start Date
Required for Subscriber
search.
EQ01- Service Type
Code
30 (Default)
Required for Subscriber
search.
*1
DTP Eligibility Start Date
MI
Subscriber Member ID
SITUATIONAL
DTP Eligibility Start Date
Subscriber Member ID
Subscriber Birth Date
Eligibility Start Date
Required for Subscriber
search.
SITUATIONAL
DTP Eligibility Start Date
SITUATIONAL
Loop 2110C
EQ - Service Type
Code
SITUATIONAL
Page 56 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent
NM103 - Dependent
Last Name
Last Name
REQUIRED
NM1 Dependent
First Name
NM104 - Dependent
First Name
*2
DMG Dependent Birth
Date
DMG02 – Dependent
Date of Birth
CCYYMMDD
Dependent Birth Date
*2
INS Dependent
Relationship
INS02 – Individual
Relationship Code
01 = Spouse
19 = Child
34 = Other Adult
Required for Dependent search.
DTP Eligibility Start
Date
DTP01 – Date/Time
Qualifier
472
Eligibility Start Date
Required for Dependent
search.
DTP02 – Date/Time
Format Qualifier
D8
CCMMYYDD
DTP03 - Eligibility
Start Date
CCYYMMDD
Eligibility Start Date
Required for Dependent
search.
EQ01- Service Type
Code
30 (Default)
Required for Dependent
search.
SITUATIONAL
DTP Eligibility Start Date
SITUATIONAL
DTP Eligibility Start Date
SITUATIONAL
Loop 2110D
EQ - Service Type
Code
SITUATIONAL
Page 57 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Coventry Health Care
Search Options
Code
*1
*2
*3
*4
*5
*6
Search Option
Subscriber 1
Subscriber 2
Subscriber 3
Subscriber 4
Dependent 1
Dependent 2
Field 1 Search
Subscriber Member ID
Subscriber Medicaid ID
Subscriber SSN
Subscriber Group Number
Subscriber Member ID
Subscriber Member ID
Field 2 Search
Subscriber DOB
Subscriber Last Name
Dependent DOB
Dependent Last Name
Field 3 Search
Subscriber First Name
Dependent First Name
Payer Name
Payer Name
Altius Health Plans
Coventry Health American/Health Assurance of Pennsylvania
Coventry Health Care Carelink Medicaid
Coventry Health Care Carelink (Advantra)
Coventry Health Care Carenet (Medicaid)
Coventry Health Group Health Plan
Coventry Health Care USA (HCUSA)
Coventry Health Care of Carolinas/Wellpath Select
Coventry Health Care of Delaware
Coventry Health Care of Georgia
Coventry Health Care of Illinois/ Personal Care
Coventry Health Care of Iowa
Coventry Health Care of Kansas, Kansas City
Coventry Health Care of Kansas, Wichita
Coventry Health Care of Louisiana
Coventry Health Care of Nebraska
Coventry Health Southern Health Services (SHS)
Payer ID ^
00364
00148
00182
00160
00190
00184
00186
25129
25130
25127
00179
25132
25133
25134
25135
25136
25128
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
See Payer Codes
above.
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Page 58 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Name
REQUIRED
NM1 Information
Receiver Name
REQUIRED
NM1 Information
Receiver Name
SITUATIONAL
NM101 - Entity
Identifier Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
SV
Service Provider Number
NM1 Information
Receiver Name
NM109 - Identification
Code
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider ID
SITUATIONAL
REF Information
Receiver Service
Provider ID
SITUATIONAL
REF01 – Identification
Code Qualifier
Receiver ID assigned by the
payer to the provider.
Service Provider Number
Receiver ID assigned by the
payer to the provider.
XX
Service Provider NPI
Service Provider NPI
N5
Service Provider Number
Receiver ID assigned by the
payer to the provider.
REF02 – Identification
Code
Service Provider Number
Receiver ID assigned by the
payer to the provider.
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
NM108 - Identification
MI
Subscriber Member ID
Member ID
Code Qualifier
*1, *5, *6
NM1 Subscriber
Member ID
NM109 - Identification
Code
Commercial Plans: 11
Subscriber Member ID
numeric digits; no special
characters.
Medicaid Plans: 10
numeric digits; no special
characters
*1, *5, *6
REF Subscriber Family
Unit Number
REF01 - Reference
Identification Qualifier
OPTIONAL
REF Subscriber Family
Unit Number
OPTIONAL
Page 59 of 259
REF02 – Reference
Identification
49
Family Unit Number
Subscriber ID Suffix may be
placed here.
Family Unit Number
Subscriber ID Suffix may be
placed here.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Subscriber
Medicaid ID
REF01 - Reference
Identification Qualifier
*2
REF Subscriber
Medicaid ID
REF02 – Reference
Identification
*2
REF Subscriber
Group Number
REF01 - Reference
Identification Qualifier
*4
REF Subscriber
Group Number
REF02 – Reference
Identification
*4
REF Subscriber SSN
*3
REF Subscriber SSN
REF01 - Reference
Identification Qualifier
NQ
Medicaid Recipient Identification
Number must be 8, 10, 11, or 12
digits.
6P
SY
REF02 – Reference
Identification
*4
NM1 Subscriber
First Name
NM104 - Subscriber
First Name
*4
DMG Subscriber
Birth Date
DMG02 - Subscriber
Birth Date
CCYMMDD
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Format Qualifier
D8
DTP03 - Service Start
Date
CCYYMMDD
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110C
EQ - Service Type
Code
Social Security Number
Social Security Number
NM103 - Subscriber
Last Name
SITUATIONAL
DTP Service Start Date
Group Number
Group Number
*3
NM1 Subscriber
Last Name
*3
DTP Service Start Date
Medicaid Recipient Identification
Number must be 8, 10, 11, or 12
digits.
Subscriber Birth Date
Service Start Date
Required for Subscriber search.
Service Start Date
Required for Subscriber search.
Cannot be more than 18 months
to current date or more than 3
months in the future.
DTP01 - Date/Time
Qualifier
472
Service End Date
DTP02 – Date/Time
Format Qualifier
RD8
Service End Date Range
DTP03 - Service Start
Date
CCYYMMDD CCYYMMDD
Service End Date
EQ01- Service Type
Code
Cannot be more than 18 months
prior to current date or more
than 3 months in the future.
Required for Subscriber
search.
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Page 60 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent
Last Name
NM103 - Dependent
Last Name
*6
NM1 Dependent
First Name
NM104 - Dependent
First Name
*6
DMG Dependent
Birth Date
DMG02 – Dependent
Date of Birth
CCYYMMDD
Dependent Birth Date
*5
INS Dependent
Relationship
SITUATIONAL
INS Dependent
Relationship
INS01 – Yes/No
Condition or Response
Code
INS02 – Individual
Relationship Code
N = No
Required for Dependent search.
01 = Spouse
19 = Child
34 = Other Adult
Required for Dependent search.
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Format Qualifier
D8
DTP03 - Service Start
Date
CCYYMMDD
DTP Service Start Date
Required for Dependent
search.
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
Service Start Date
Required for Dependent
search.
Cannot be more than 18 months
prior to current date or more
than 3 months in the future.
SITUATIONAL
DTP Service End Date
OPTIONAL
DTP01 – Date/Time
Qualifier
472
Service End Date
DTP Service End Date
OPTIONAL
DTP02 – Date/Time
Format Qualifier
RD8
Service End Date Range
DTP Service End Date
DTP03 - Service Start
Date
CCYYMMDD CCYYMMDD
Service End Date
OPTIONAL
Loop 2110D
EQ - Service Type
Code
EQ01- Service Type
Code
Cannot be more than 18 months
prior to current date or more
than 3 months in the future.
Required for Dependent
search.
SITUATIONAL
Page 61 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Diamond Plan (MD Medicaid)
Search Options
Code
*1
*2
*3
*4
*5
*6
Search
Option
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Subscriber
Member ID
Subscriber
Medicaid ID
Subscriber
SSN
Subscriber
Name
Dependent
Name
Dependent
DOB
Subscriber
Member ID
Subscriber
Medicaid ID
Subscriber
SSN
Subscriber
Group Number
Subscriber
Member ID
Subscriber
Member ID
Service Start
Date
Service Start
Date
Subscriber
DOB
Subscriber
Last Name
Dependent
Relationship
Dependent
Relationship
Service Start
Date
Subscriber
First Name
Dependent
Last Name
Dependent
DOB
Service Start
Date
Dependent
First Name
Service Start
Date
Service
Start Date
Payer Name
Payer Name
Diamond Plan (MD Medicaid)
Payer ID
00177
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
Reference
Designator(s)
Value
Definitions and Notes
Specific to ICS
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
00177
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
NM101 - Entity Identifier Code
1P
Provider
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
Page 62 of 259
NM102 – Entity Type Qualifier
2
Non-Person Entity
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider Tax ID
NM108 – Identification Code
Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider Tax ID
NM109 – Identification Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification Code
Qualifier
FI
Service Provider Tax ID
Service Provider Tax ID
XX
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
NM109 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider NPI
TJ
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
REF02 – Identification Code
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*4
NM1 Subscriber First Name
*4
NM1 Subscriber Member ID
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
NM108 – Identification Code
Qualifier
*1, *5, *6
NM1 Subscriber Member ID
NM109 – Identification Code
*1, *5, *6
REF Subscriber Group
Number
REF01 – Reference
Identification Qualifier
*4
REF Subscriber Group
Number
*4
REF Subscriber SSN
*3
REF Subscriber SSN
*3
NM1 Subscriber Medicaid ID
MI
Subscriber Member ID
6P
REF02 – Reference
Identification
REF01 – Reference
Identification Qualifier
Subscriber Group Number
Subscriber Group Number
SY
REF02 – Reference
Identification Number
NM101 – Entity Code
Identifier
Subscriber Member ID
Social Security Number
Social Security Number
IL
Subscriber Medicaid ID
*2
Page 63 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Subscriber Medicaid ID
*2
NM1 Subscriber Medicaid ID
*2
NM1 Subscriber Medicaid ID
*2
DMG Subscriber Birth Date
NM102 – Entity Type Qualifier
1
Person
REF01 – Reference
Identification Qualifier
NQ
Medicaid Recipient
Identification Number
REF02 – Reference
Identification
Medicaid Recipient
Identification Number
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time Qualifier
472
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
Service Start Date
*1, *2, *3, *4
DTP Service Start Date
DTP03 – Service Start Date
CCYYMMDD
Service Start Date
*1, *2, *3, *4
DTP Service End Date
DTP01 – Date/Time Qualifier
472
Service End Date
DTP02 – Date/Time Period
Format Qualifier
D8
Service End Date
DTP03 – Date/Time Period
Format Qualifier
CCYYMMDD
Service End Date
EQ01- Service Type Code
30
Service Type Code
*3
DTP Service Start Date
*1, *2, *3, *4
DTP Service Start Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110C
EQ - Service Type Code
*1, *2, *3, *4
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
*5
NM1 Dependent First Name
*5
DMG Dependent Birth Date
*6
INS Individual Relationship
NM103 – Dependent Last
Name
Dependent Last Name
NM104 – Dependent First
Name
Dependent First Name
DMG02 – Dependent Date of
Birth
CCYYMMDD
INS02 – Individual
Relationship Code
01 = Spouse
19 = Child
34 = Other
Adult
472
*5, *6
DTP Service Start Date
*5, *6
Page 64 of 259
DTP01 – Date/Time Qualifier
Required for Dependent
search.
Service Start Date
Required for Dependent
search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP02 – Date/Time Format
Qualifier
D8
Service Start Date
*5, *6
DTP Service Start Date
DTP03 - Service Start Date
CCYYMMDD
*5, *6
DTP Service End Date
Required for Dependent
search.
DTP01 – Date/Time Qualifier
472
Service End Date
DTP02 – Date/Time Format
Qualifier
D8
Service End Date
DTP03 - Service Start Date
CCYYMMDD
Service End Date
EQ01- Service Type Code
30
DTP Service Start Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110D
EQ - Service Type Code
*5, *6
Page 65 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Fidelis (CenterCare)
Search Options
Code
Search Option
Field 1 Search
Field 2 Search
Field 3 Search
*1
Subscriber 1
Member ID Number
*2
Subscriber 2
Member ID Number
Subscriber DOB
*3
Subscriber 3
Member ID Number
Subscriber SSN
*4
Subscriber 4
Subscriber Last Name Subscriber First Name
Subscriber DOB
*5
Subscriber 5
Subscriber Last Name Subscriber First Name
Subscriber SSN
Subscriber Last Name Subscriber First Name
Payer Name
Payer Name
Fidelis (CenterCare)
Payer ID
FIDEL
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Entity Identifier Code
Identifier Code
REQUIRED
NM1 Information Source
Entity Identifier Code
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM1 Information Source
Payer ID
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
FIDEL
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
1
Person
Receiver Entity Identifier
Qualifier
Code
REQUIRED
Page 66 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Organization
Name
SITUATIONAL
NM1 Information
Receiver First Name
NM103 – Organization
Name
Organization Name
NM103 – First Name
Service Provider First Name
NM104 – First Name
Service Provider First Name
SITUATIONAL
NM1 Information
Receiver First Name
SITUATIONAL
NM1 Information
Receiver Provider ID
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Provider ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SV
Service Provider ID
Service Provider ID
XX
Service Provider ID, Tax ID, or
NPI is required.
Service Provider ID, Tax ID, or
NPI is required.
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last
Name
*1, *4, *5
NM1 Subscriber First
Name
NM103 – Last Name
NM104 – First Name
*1, *4, *5
NM1 Subscriber Member
ID
NM108 – Identification
Code Qualifier
*1, *2, *3
NM1 Subscriber Member
ID
NM109 – Identification
Code
MI
Subscriber Member ID
Subscriber Member ID
*1, *2, *3
Page 67 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Subscriber Social
Security Number
*3, *5
REF Subscriber Social
Security Number
*3, *5
DMG Subscriber Birth
Date
*2, *4
DMG Subscriber Birth
Date
REF01 – Reference
Identification Qualifier
SY
REF02 – Reference
Identification
Subscriber Social Security
Number
Subscriber Social Security
Number
DMG01 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
DMG02 – Subscriber
Birth Date
CCYYMMDD
EQ01- Service Type
Code
30
Subscriber Birth Date
*2, *4
Loop 2110C
EQ - Service Type
Code
SITUATIONAL
Page 68 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
First Ameritas of New York
Search Options
Code
*1
*2
Search
Option
Subscriber
1
Subscriber
2
Field 1 Search
Subscriber
Member ID
Subscriber
Member ID
Field 2 Search
Subscriber Last
Name
Dependent First
Name
Field 3 Search
Subscriber First
Name
Dependent First
Name
Field 4 Search
Subscriber
Birth Date
Dependent
Birth Date
Payer Name
Payer Name
First Ameritas of New York
Payer ID ^
00426
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Name
Qualifier
REQUIRED
NM1 Information Source
NM108 – Identification PI
Payer Identification
Name
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
00426
Carrier ID
Name
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
1
Person
2
Non-Person Entity
Receiver Entity Identifier
Qualifier
Code
REQUIRED
NM1 Information
NM108 – Identification FI
Federal Tax ID Number
Receiver Provider Tax ID Code Qualifier
SITUATIONAL
NM1 Information
NM109 – Identification
Federal Tax ID Number
Receiver Provider Tax ID Code
SITUATIONAL
Page 69 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM108 – Identification
Code Qualifier
NM1 Information
Receiver Service
Provider NPI
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF02 – Tax ID
Identification Code
XX
Service Provider NPI
Service Provider NPI
TJ
Service Provider Tax ID
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
MI
Members SSN
Designator(s)
Loop 2100C
NM Subscriber
Member ID
NM108 – Identification
Code Qualifier
*1, *2
NM Subscriber
Member ID
NM109 – Identification
Code
*1, *2
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
*1
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
*1
DMG Subscriber
Birth Date
*1
DMG Subscriber
Birth Date
*1
DTP Eligibility Start Date
SITUATIONAL
DTP Eligibility Start Date
SITUATIONAL
DTP Eligibility Start Date
SITUATIONAL
Page 70 of 259
Members SSN
DMG01 – Date/Time
Period Format
Qualifier
D8
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
307
Eligibility Date
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Service Start
Date
D8
Required for Subscriber search.
CCYYMMDD
Eligibility Start Date
Required for Subscriber search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2110C
EQ - Service Type
Code
EQ01- Service Type
Code
30
Required for Subscriber
search.
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
Designator(s)
to ICS
Loop 2100D
NM Dependent
NM103 – Dependent
Last Name
Last Name
*2
NM Dependent
First Name
*2
NM Dependent
Birth Date
NM104 – Dependent
First Name
DMG01 – Date/Time
Period Format
Qualifier
D8
DMG02 – Dependent
Birth Date
CCYYMMDD
Dependent Birth Date
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
D8
DTP03 – Eligibility
Start Date
CCYYMMDD
EQ01- Service Type
Code
30
*2
NM Dependent
Birth Date
*2
DTP Eligibility Start Date
REQUIRED
DTP Eligibility Start Date
REQUIRED
DTP Eligibility Start Date
Eligibility Start Date
REQUIRED
Loop 2110D
EQ - Service Type
Code
REQUIRED
Page 71 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
First Health
Search Options
Code
Search Option
*1
Subscriber 1
*2
Dependent 1
Field 1 Search
Subscriber Last
Name
Dependent Last
Name
Field 2 Search
Subscriber First
Name
Dependent First
Name
Field 3 Search
Subscriber DOB
Dependent DOB
Payer Name
Payer Name
First Health
Payer ID ^
87043
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
87043
Carrier ID
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Name
NM101 - Entity
Identifier Code
1P
Provider
REQUIRED
NM1 Information
Receiver Name
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
FI
Federal Tax ID Number
One of the following is required:
Federal Tax ID, SSN or Service
Provider ID
REQUIRED
NM1 Information
Receiver Tax ID
SITUATIONAL
Page 72 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Name
NM109 - Identification
Code
SITUATIONAL
NM1 Information
Receiver SSN
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Name
NM109 – Identification
Code
SITUATIONAL
NM1 Information
Receiver Service
Provider ID
SITUATIONAL
NM1 Information
Receiver Name
NM108 – Identification
Code Qualifier
Federal Tax ID Number
34
Social Security Number
One of the following is required:
Federal Tax ID, SSN or Service
Provider ID
Social Security Number
SV
Service Provider ID
One of the following is required:
Federal Tax ID, SSN or Service
Provider ID
NM109 - Identification
Code
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF02 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
Service Provider ID
XX
Service Provider NPI
Service Provider NPI
TJ
Service Provider Tax ID
Service Provider Tax ID
Q4
Service Provider ID
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF02 – Identification
Code
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Designator(s)
Value
Definitions and Notes Specific
to ICS
Loop 2100C
Page 73 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Subscriber
Member ID
NM108 - Identification
Code Qualifier
REQUIRED
NM1 Subscriber
Member ID
NM109 - Identification
Code
Subscriber Member ID
REQUIRED
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
Subscriber Last Name
*1
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
Subscriber First Name
*1
DMG Subscriber
Birth Date
DMG02 – Subscriber
Birth Date
CCMMYYDD
Subscriber Birth Date
*1
REF Subscribe
Group Number
REF01 – Reference
Identification Qualifier
6P
Group Number
MI
Subscriber Member ID
OPTIONAL
REF Subscriber
Group Number
REF02 - Reference
Identification
DTP Service Start Date
DTP01 – Date/Time
Qualifier
472
DTP Service Start Date
DTP02 – Date/Time
Format Qualifier
D8
CCYYMMDD
DTP Service Start Date
DTP03 – Service Start
Date
CCYYMMDD
EQ01 - Service Start
Date
30
SITUATIONAL
Loop 2110C
EQ - Service Type
Code
Group Number
Service Start Date
Required for Subscriber search.
Service Start Date
Required for Subscriber search.
Required for Subscriber search.
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last
Name
NM103 - Dependent
Last Name
Code
*2
NM1 Dependent First
Name
NM104 - Dependent
First Name
*2
Page 74 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DMG02 – Dependent
Date of Birth
CCYYMMDD
Dependent Birth Date
REF Dependent Group
Number
REF01 – Reference
Identification Qualifier
6P
Group Number
OPTIONAL
REF Dependent Group
Number
REF02 – Reference
Identification
DMG Dependent Birth
Date
*2
Group Number
DTP01 – Date/Time
Qualifier
472
DTP Service Start Date
DTP02 – Date/Time
Format Qualifier
D8
CCMMYYDD
Required for Dependent search.
DTP Service Start Date
DTP03 - Service Start
Date
CCYYMMDD
Service Start Date
EQ01- Service Type
Code
30
DTP Service Start Date
Service Start Date
Required for Dependent search.
SITUATIONAL
Loop 2110D
EQ - Service Type
Code
Required for Dependent search.
Required for Dependent search.
SITUATIONAL
Page 75 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
First Health (Mail Handlers)
Search Options
Code
Search Option
*1
Subscriber
*2
Dependent
Field 1 Search
Subscriber
Last Name
Dependent
Last Name
Field 2 Search
Subscriber
First Name
Dependent
First Name
Field 3 Search
Field 4 Search
Subscriber DOB
Dependent DOB
Dependent
Relationship
Payer Name
Payer Name
Mail Handlers
Payer ID ^
00251
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
00251
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
Receiver Name
REQUIRED
NM1 Information
Receiver Name
REQUIRED
NM1 Information
Receiver Tax ID
NM101 - Entity
Identifier Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
FI
Federal Tax ID
One of the following is required:
Federal Tax ID, SSN, Service
Provider ID, or NPI.
SITUATIONAL
NM1 Information
Receiver Name
SITUATIONAL
Page 76 of 259
NM109 - Identification
Code
Federal Tax ID
One of the following is required:
Federal Tax ID, SSN, Service
Provider ID, or NPI.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver SSN
NM108 – Identification
Code Qualifier
34
SITUATIONAL
NM1 Information
Receiver Name
NM109 – Identification
Code
Social Security Number
One of the following is required:
Federal Tax ID, SSN, Service
Provider ID, or NPI.
SITUATIONAL
NM1 Information
Receiver Service
Provider ID
NM108 – Identification
Code Qualifier
Social Security Number
One of the following is required:
Federal Tax ID, SSN, Service
Provider ID, or NPI.
SV
Service Provider ID
One of the following is required:
Federal Tax ID, SSN, Service
Provider ID, or NPI.
SITUATIONAL
NM1 Information
Receiver Name
NM109 - Identification
Code
Service Provider ID
One of the following is required:
Federal Tax ID, SSN, Service
Provider ID, or NPI.
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
XX
Service Provider NPI
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
Service Provider NPI
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF01 – Identification
Code Qualifier
TJ
Service Provider Tax ID
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF02 – Identification
Code
Service Provider Tax ID
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
Q4
Service Provider ID
SITUATIONAL
REF Information
Receiver Service
Provider ID
SITUATIONAL
REF02 – Identification
Code
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
Member ID
NM108 - Identification
Code Qualifier
MI
Subscriber Member ID
REQUIRED
Page 77 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Subscriber
Member ID
NM109 - Identification
Code
Subscriber Member ID
REQUIRED
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
Subscriber Last Name
NM104 – Subscriber
First Name
Subscriber First Name
*1
NM1 Subscriber
First Name
*1
DMG Subscriber
Birth Date
DMG02 – Subscriber
Birth Date
CCMMYYDD
Subscriber Birth Date
REF01 – Reference
Identification Qualifier
6P
Group Number
*1
REF Subscribe
Group Number
OPTIONAL
REF Subscriber
Group Number
REF02 - Reference
Identification
DTP Service Start Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
Required for Subscriber search.
DTP02 – Date/Time
Format Qualifier
D8
.
DTP03 – Service Start
Date
CCYYMMDD
Service Start Date
Required for Subscriber
search.
EQ01- Service Start
Date
30
Required for Subscriber
search.
SITUATIONAL
DTP Service Start Date
DTP Service Start Date
Loop 2110C
EQ - Service Type
Code
Reference Identification
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent
NM103 - Dependent
Last Name
Last Name
Code
*2
NM1 Dependent
NM104 - Dependent
First Name
First Name
*2
DMG Dependent
Birth Date
DMG02 – Dependent
Date of Birth
CCYYMMDD
Dependent Birth Date
*2
REF Dependent
Group Number
REF01 – Reference
Identification Qualifier
6P
Group Number
OPTIONAL
Page 78 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Dependent
Group Number
REF02 – Reference
Identification
INS Dependent
Relationship
INS01 – Yes/No
Condition
N
Required for Dependent
search.
INS02 – Individual
Relationship Code
01- Spouse
19- Child
34- Other Adult
Required for Dependent
search.
*2
SITUATIONAL
INS Dependent
Relationship
*2
SITUATIONAL
INS Dependent
Relationship
Group Number
INS17 – Birth
Sequence Number
This is the number assigned to
each family member born with
the same birth date. This
number identifies birth sequence
for multiple births allowing
proper tracking and response of
benefits for each dependent (i.e.
twins, triplets, etc.)
*2
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
DTP Service Start Date
Loop 2110D
EQ - Service Type
Code
.
DTP01 – Date/Time
Qualifier
472
Service Start Date
Required for Dependent
search.
DTP02 – Date/Time
Format Qualifier
D8
CCMMYYDD
DTP03 - Service Start
Date
CCYYMMDD
Required for Dependent
search.
Service Start Date
Required for Dependent
search.
EQ01- Service Type
Code
30
Required for Dependent
search.
SITUATIONAL
Page 79 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Florida Blue Cross Blue Shield
Search Options
Code
Search
Option
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
*1
Subscriber
Subscriber
Last Name
Subscriber
First Name
Subscriber
Member ID
Subscriber
DOB
Service Start
Date
*2
Dependent
Dependent
Last Name
Dependent
First Name
Dependent
DOB
Subscriber
Member ID
Relationship
to Insured
Field 6
Search
Service
Start Date
Payer Name
Payer Name
Florida Blue Cross Blue Shield
Payer ID ^
FLBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Name
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Name
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
FLBLS
Carrier ID
Name
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Service
Provider ID
SITUATIONAL
Page 80 of 259
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification
Code Qualifier
SV
Service Provider ID
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Provider ID
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
SITUATIONAL
REF Information
Receiver Service
Provider ID
SITUATIONAL
REF Information
Receiver Service
Provider ID
NM109 – Identification
Code
NM108 – Identification
Code Qualifier
Provider ID
XX
NM109 – Identification
Code
REF01 – Identification
Code Qualifier
Service Provider NPI
Service Provider NPI
Q4
REF02 – Identification
Code
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
NM108 – Identification MI
Subscriber Member ID
Member ID
Code Qualifier
REQUIRED
NM Subscriber
NM109 – Identification
Subscriber Member ID
Member ID
Code
REQUIRED
DMG Subscriber
DMG02 – Subscriber
CCYYMMDD
Birth Date
Birth Date
*1
SITUATIONAL
DTP Service Start Date
DTP01 – Date/Time
472
Service Start Date
Qualifier
*1
SITUATIONAL
DTP Service Start Date
*1
DTP Service Start Date
*1
SITUATIONAL
Loop 2110C
EQ - Service Type
Code
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Service Start
Date
D8
EQ01- Service Type
Code
30
CCYYMMDD
*1
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Page 81 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D
NM1 Dependent Last
Name
NM103 – Dependent
Last Name
Required if patient is the
Dependent.
NM104 – Dependent
First Name
Required if patient is the
Dependent.
*2
SITUATIONAL
NM1 Dependent First
Name
*2
SITUATIONAL
DMG Dependent Birth
Date
DMG02 – Dependent
Birth Date
CCYYMMDD
Required if patient is the
Dependent.
INS01 – Yes/No
Condition
N
Required for Dependent
search.
INS02 – Individual
Relationship Code
01- Spouse
19- Child
34- Other Adult
Required for Dependent
search.
*2
SITUATIONAL
INS Dependent
Relationship
*2
SITUATIONAL
INS Dependent
Relationship
*2
SITUATIONAL
INS Dependent
Relationship
SITUATIONAL
INS17 – Birth Sequence
Number
DTP Service Start Date
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
EQ01- Service Type
Code
30
*2
SITUATIONAL
DTP Service Start Date
*2
SITUATIONAL
DTP Service Start Date
*2
SITUATIONAL
Loop 2110D
EQ - Service Type
Code
This is the number assigned to
each family member born with
the same birth date. This
number identifies birth sequence
for multiple births allowing proper
tracking and response of benefits
for each dependent (i.e. twins,
triplets, etc.).
Service Start Date
*2
Page 82 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Florida Medicaid
Search Options
Code
Search
Option
*1
Subscriber 1
*2
*3
Subscriber 2
Subscriber 3
*4
Subscriber 4
*5
Dependent 1
Field 1 Search
Subscriber
Member ID
Subscriber Card
Control Number@
Subscriber SSN
Subscriber SSN
Subscriber
Last Name
Field 2 Search
Subscriber DOB
Subscriber
Last Name
Subscriber
First Name
Field 3 Search
Field 4
Search
Subscriber
First Name
Subscriber DOB
Subscriber
Gender
@Card Swipe
Payer Name
Payer Name
Florida Medicaid
Payer ID
FLMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity Identifier
PR
Payer
Name
Code
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Name
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
FLMCD
Carrier ID
Name
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
NM101 - Entity Identifier
1P (School
Provider
District)
Entity Identifier Code
Code
2B (DHACS)
REQUIRED
NM1 Information Receiver
Service Provider ID
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider ID
NM109 – Identification
Code
SV
Florida Medicaid Provider ID
Number
Florida Medicaid Provider ID
Number
SITUATIONAL
Page 83 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information Receiver
Service Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information Receiver
Service Provider ID
REF02 – Identification
Code
XX
Service Provider NPI
Service Provider NPI
1D
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
Member ID
NM108 – Identification
Code Qualifier
MI
Medicaid Recipient ID
*1
NM1 Subscriber
Member ID
NM109 – Identification
Code
Medicaid Recipient ID
*1
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
*4, *5
NM1 Subscriber
First Name
*4, *5
REF Subscriber SSN
*3, *4
REF Subscriber SSN
*3, *4
REF Subscriber Card
Control Number @
NM104 – Subscriber
First Name
REF01 – Reference
Identification Qualifier
SY
REF02 – Reference
Identification Number
REF01 – Reference
Identification Qualifier
Social Security Number
Social Security Number
HJ
Card ID Number
*2
REF Subscriber Card
Control Number @
REF02 - Reference
Identification Number
*2
DMG Subscriber Birth
Date
DMG02 – Subscriber
Birth Date
Card ID Number
CCMMYYDD
Subscriber Birth Date
*3, *5
Page 84 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DMG Subscriber Gender
*5
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
Loop 2110C
EQ - Service Type
Code
DMG03 – Gender
Code
F = Female
M = Male
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Format Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
EQ01- Service Type
Code
30
Service Start Date
Service Start Date
REQUIRED
@Indicates that field data may be obtained from card swipe.
Page 85 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Georgia Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Code
Search
Option
*1
Subscriber
*2
Dependent
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Subscriber
Last Name
Subscriber
Last Name
Subscriber
First Name
Subscriber
First Name
Subscriber
Birth Date
Subscriber
Member ID
Subscriber
Member ID
Dependent
Last Name
Subscriber
Gender
Dependent
First Name
Dependent
Birth Date
Dependent
Gender
Payer Name
Payer Name
Georgia Blue Cross Blue Shield
Payer ID ^
GABLS
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
Name
NM102 – Entity Type
Qualifier
2
Non-Person Entity
REQUIRED
NM1 Information Source
Name
NM108 - Identification
Code Qualifier
PI
Payer Identification
REQUIRED
NM1 Information Source
Name
NM109 - Identification
Code
GABLS
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
Receiver Entity Identifier
Code
Page 86 of 259
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REQUIRED
NM1 Information
Receiver Service
Provider ID
REQUIRED
NM1 Information
Receiver Provider ID
REQUIRED
REF Information
Receiver Service
Provider ID
SITUATIONAL
REF Information
Receiver Service
Provider ID
SITUATIONAL
NM108 – Identification
Code Qualifier
SV
XX
Provider ID
NPI
Q4
If NM108 is equals SV should
use Provider ID.
If NM108 is equals XX should
use NPI.
Service Provider ID
NM109 – Identification
Code
REF01 – Identification
Code Qualifier
REF02 – Identification
Code
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
Member ID
NM108 – Identification
Code Qualifier
REQUIRED
NM Subscriber
Member ID
NM109 – Identification
Code
Subscriber Member ID
NM103 – Subscriber
Last Name
Required for Subscriber Search.
NM104 – Subscriber
First Name
Required for Subscriber Search.
REQUIRED
NM1 Subscriber
Last Name
*1
SITUATIONAL
NM1 Subscriber
First Name
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber
Birth Date
MI
Subscriber Member ID
DMG01 – Subscriber
Birth Date
D8
Required for Subscriber Search.
DMG02 – Subscriber
Birth Date
CCYYMMDD
Required for Subscriber Search.
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
*1
SITUATIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Page 87 of 259
CCYYMMDDCCYYMMDD
Range of dates in which the
provider is querying verification
about a patient’s eligibility. It is
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
OPTIONAL
strongly suggested that this field
be populated.
Loop 2110C
EQ - Service Type
Code
EQ01- Service Type
Code
30
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent
Last Name
*2
SITUATIONAL
NM1 Dependent
First Name
*2
SITUATIONAL
DMG Dependent
Birth Date
*2
SITUATIONAL
DMG Dependent
Birth Date
*2
NM103 – Dependent
Last Name
Required for Dependent Search.
NM104 – Dependent
First Name
Required for Dependent Search.
DMG01 – Dependent
Birth Date
D8
Required for Dependent Search.
DMG02 – Dependent
Birth Date
CCYYMMDD
Required for Dependent Search.
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
EQ01- Service Type
Code
30
SITUATIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110D
EQ - Service Type
Code
CCYYMMDDCCYYMMDD
Range of dates in which the
provider is querying verification
about a patient’s eligibility. It is
strongly suggested that this field
be populated.
SITUATIONAL
Page 88 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Government Employees Hospital Association (GEHA)
Search Options
Code
Search
Option
*1
Subscriber 1
*2
Subscriber 2
*3
Dependent 1
*4
Dependent 2
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Subscriber
Member ID
Subscriber
SSN
Subscriber
Member ID
Subscriber
SSN
Subscriber
Last Name
Subscriber
Last Name
Dependent
Last Name
Dependent
Last Name
Subscriber
First Name
Subscriber
First Name
Dependent
First Name
Dependent
First Name
Subscriber
DOB
Subscriber
DOB
Dependent
DOB
Dependent
DOB
Subscriber
Gender
Subscriber
Gender
Dependent
Gender
Dependent
Gender
Payer Name
Payer Name
Government Employees Hospital Association (GEHA)
Payer ID
44054
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity Identifier PR
Payer
Entity Identifier Code
Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Entity Identifier Code
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Payer ID
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
Carrier ID
44054
Payer ID
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Organization Name
SITUATIONAL
NM1 Information Receiver
Last Name
Page 89 of 259
NM101 - Entity Identifier
code
1P
Provider
NM102 – Entity Type
Qualifier
2
1
Non-Person Entity
Person
NM103 – Organization
Name
Organization Name
NM103 – Last Name
Service Provider Last Name
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
SITUATIONAL
NM1 Information Receiver
First Name
NM104 – First Name
SITUATIONAL
NM1 Information Receiver
Provider Tax ID
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Provider Tax ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
Service Provider First Name
FI
Service Provider ID
Service Provider Tax ID or NPI
is required
XX
Service Provider ID
Service Provider Tax ID or NPI
is required.
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Last Name
Subscriber Last Name
*1, *2
NM1 Subscriber First Name
*1, *2
NM1 Subscriber Member ID
*1, *3
NM1 Subscriber Member ID
*1, *3
NM1 Subscriber Member ID
*2, *4
NM1 Subscriber Member ID
*2, *4
DMG Subscriber Birth Date
*1, *2
DMG Subscriber Birth Date
*1, *2
DMG Subscriber Gender
NM104 – First Name
NM108 – Identification
Code Qualifier
NM109 – Identification
Code
Subscriber First Name
MI
Subscriber Member ID
Subscriber Member ID
The Member ID can either be
the SSN (9 positions) or the
GEHA ID (8 positions). The
GEHA ID MUST NOT be ZERO
filled to create a 9 position ID.
NM108 – Identification
Code Qualifier
NM109 – Identification
Code
MI
Subscriber SSN
Subscriber SSN
The Member ID can either be
the SSN (9 positions) or the
GEHA ID (8 positions). The
GEHA ID MUST NOT be ZERO
filled to create a 9 position ID.
DMG01 – Date/Time
Period Format Qualifier
D8
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date
DMG03 – Gender Code
F = Female
M = Male
Subscriber Gender Code
*1, *2
Page 90 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
Loop 2110C
EQ Coverage Level Code
REQUIRED
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Period Format Qualifier
D8
Service Start Date Range
DTP03 – Eligibility Date
CCYYMMDD
Service Start Date
EQ01 – Benefit
Coverage Level Code
30
Benefit Service Type Code
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
*3, *4
NM103 – Last Name
Dependent Last Name
NM1 Dependent First Name
NM104 – First Name
Dependent First Name
*3, *4
DMG Dependent Birth Date
*3, *4
DMG Dependent Birth Date
*3, *4
DMG Subscriber Gender
*3, *4
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
Loop 2110D
EQ Coverage Level Code
REQUIRED
Page 91 of 259
DMG01 – Date/Time
Period Format Qualifier
D8
Dependent Birth Date
DMG02 – Dependent
Birth Date
CCYYMMDD
Dependent Birth Date
DMG03 – Gender Code
F = Female
M = Male
Subscriber Gender Code
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Period Format Qualifier
D8
Service Start Date Range
DTP03 – Eligibility Date
CCYYMMDD
Service Start Date
EQ01 – Benefit
Coverage Level Code
30
Benefit Service Type Code
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Health Net of Arizona
Search Options Not Applicable.
Payer Name
Payer Name
Health Net of Arizona
Payer ID ^
00213
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Name
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Name
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
00213
Carrier ID
Name
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Name
Identifier Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Name
Qualifier
REQUIRED
NM1 Information
NM108 – Identification FI
Federal Tax ID Number
Receiver Tax ID
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Tax ID
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
NM108 – Identification
Code Qualifier
NM109 – Identification
Code
Federal Tax ID Number
XX
Service Provider NPI
Service Provider NPI
SITUATIONAL
Page 92 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
REF01 – Identification
Code Qualifier
TJ
REF02 – Identification
Code
Service Provider Tax ID
Service Provider Tax ID
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
NM103 – Subscriber
Last Name
Last Name
REQUIRED
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
REQUIRED
NM1 Subscriber
Member ID
NM108 – Identification
Code Qualifier
MI
Subscriber Member ID
REQUIRED
NM1 Subscriber
Member ID
NM109 – Identification
Code
Subscriber Member ID
REQUIRED
DMG Subscriber
Birth Date
DMG02 – Subscriber
Birth Date
CCMMYYDD
Subscriber Birth Date
DMG03 – Gender
Code
F = Female
M = Male
Subscriber Gender Code
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Format Qualifier
D8
DTP03 – Service Start
Date
CCYYMMDD
REQUIRED
DMG Subscriber Gender
OPTIONAL
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
Service Start Date
REQUIRED
Loop 2110C
EQ - Service Type
Code
EQ01- Service Type
Code
REQUIRED
Page 93 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Health Net of the Northeast
Search Options Not Applicable.
Payer Name
Payer Name
Health Net of Northeast
Payer ID ^
00213
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Name
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Name
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
00213
Carrier ID
Name
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Name
Identifier Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Name
Qualifier
REQUIRED
NM1 Information
NM108 – Identification FI
Federal Tax ID Number
Receiver Tax ID
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Tax ID
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
NM108 – Identification
Code Qualifier
NM109 – Identification
Code
Federal Tax ID Number
XX
Service Provider NPI
Service Provider NPI
SITUATIONAL
Page 94 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
REF01 – Identification
Code Qualifier
TJ
REF02 – Identification
Code
Service Provider Tax ID
Service Provider Tax ID
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
NM103 – Subscriber
Last Name
Last Name
REQUIRED
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
REQUIRED
NM1 Subscriber
Member ID
NM108 – Identification
Code Qualifier
MI
Subscriber Member ID
REQUIRED
NM1 Subscriber
Member ID
NM109 – Identification
Code
Subscriber Member ID
REQUIRED
DMG Subscriber
Birth Date
DMG02 – Subscriber
Birth Date
CCMMYYDD
Subscriber Birth Date
DMG03 – Gender
Code
F = Female
M = Male
Subscriber Gender Code
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Format Qualifier
D8
DTP03 – Service Start
Date
CCYYMMDD
REQUIRED
DMG Subscriber Gender
OPTIONAL
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
Service Start Date
REQUIRED
Loop 2110C
EQ - Service Type
Code
EQ01- Service Type
Code
REQUIRED
Page 95 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
HealthPartners of Minnesota
This transaction utilizes the Minnesota Uniform Companion Guide for the Implementation of the Eligibility Inquiry
and Response Electronic Transaction (ANSI ASC X12 270/271), October, 2008 Version 4.0.
A copy of this companion guide can be obtained by going to:
http://www.health.state.mn.us/auc/eligguide.htm and downloading mn270271guide.pdf
Section 4.2, page 14 of mn270271guide.pdf discusses how the subscriber and patient loops may be submitted. For
example, the dependent can be submitted in the subscriber loop or submitted in the dependent loop.
This transaction requires NM103 in 2100B to be populated for a successful 270 submission, contrary to the
mn270271guide.pdf.
This transaction requires the submission of the provider’s NPI in 2100B.
The Provider must first be enrolled for eligibility with HealthPartners of MN before submitting the 270 request.
Please refer to the ICS website for a copy of the enrollment form and instructions.
One additional search option, Personal Medical Identifier, has been added to this implementation but is not
outlined in the mn270271guide.pdf.
Search Options
Code
Search
Option
*1
1
*2
2
*3
3
*4
4
*5
5
*6
6
*7
7
Field 1
Search
Patient/
Member ID
Patient/
Member ID
Patient/
Member ID
Patient/
Member ID
Patient/
Member ID
Field 2
Search
Field 3
Search
Last Name
First Name
Last Name
First Name
Last Name
First Name
Last Name
First Name
Field 4
Search
Patient
DOB
Patient
DOB
Patient
DOB
Patient
DOB
Field 5 Search
Patient
DOB
Personal Medical
Identifier
Payer Name
Payer Name
HealthPartners of MN
Payer ID
94267
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Entity Identifier Code
Identifier Code
REQUIRED
Page 96 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Source
Entity Identifier Code
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
94267
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
1,2
Person, Non-Person Entity
Receiver Entity Identifier
Qualifier
Code
REQUIRED
NM1 Information
NM103 – Last Name
Last Name or Organization
Name
Receiver Last Name or
or Organization Name
Organization Name
REQUIRED
NM1 Information
NM104 – First Name
Service Provider First Name
Receiver First Name
SITUATIONAL
NM1 Information
NM108 – Identification XX
NPI
Receiver Provider ID
Code Qualifier
REQUIRED
NM1 Information
NM109 – Identification
NPI. Provider must be enrolled
for eligibility with HP of MN
Receiver Provider ID
Code
before submitting the 270
REQUIRED
request. Please refer to the ICS
website for enrollment form and
instructions.
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
NM103 – Last Name
Last Name
Last Name
*1, *2, *5, *6
NM1 Subscriber
First Name
*1, *3, *5, *6
NM1 Patient / Member
ID Qualifier
NM104 – First Name
NM108 – Identification
Code Qualifier
First Name
MI
Identification Code Qualifier
*1, *2, *3, *4, *5
Page 97 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Patient / Member
ID
NM109 – Identification
Code
*1, *2, *3, *4, *5
REF Subscriber
Additional Identification
REF01 – Reference
Identification Qualifier
*7
REF Subscriber
Additional Identification
REF02 – Reference
Identification
*7
DMG Birth Date
*1, *2, *3, *4, *6
DMG Birth Date
*1, *2, *3, *4, *6
DTP Date
SITUATIONAL
DTP Date Time Period
Format Qualifier
SITUATIONAL
DTP Date Time Period
SITUATIONAL
Patient / Member ID
NQ
Medicaid Recipient Identification
Number – Also referred to as
Personal Medical Identifier (PMI)
Medicaid Recipient Identification
Number – Also referred to as
Personal Medical Identifier (PMI)
DMG01 – Date/Time
Period Format
Qualifier
D8
Date
DMG02 – Date/Time
Period
CCYYMMDD
Patient Date of Birth
DTP01 – Date/Time
Qualifier
DTP02 – Date/Time
Period Format
Qualifier
Service Start Date
D8
CCYYMMDD,
RD8
CCYYMMDD CCYYMMDD
DTP03 – Date Time
Period
Date, Range of Dates
Date Time Period
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent
NM103 – Last Name
Last Name
Last Name
*1, *2, *5, *6
NM1 Dependent
First Name
*1, *3, *5, *6
DMG Birth Date
*1, *2, *3, *4, *6
DMG Birth Date
*1, *2, *3, *4, *6
DTP Date
SITUATIONAL
DTP Date Time Period
Format Qualifier
SITUATIONAL
DTP Date Time Period
NM104 – First Name
DMG01 – Date/Time
Period Format
Qualifier
DMG02 – Patient Birth
Date
First Name
D8
Date
CCYYMMDD
Patient Date of Birth
DTP01 – Date/Time
Qualifier
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Service Start
Date
Service Start Date
D8
CCYYMMDD,
RD8
CCYYMMDD CCYYMMDD
Date, Range of Dates
Date Time Period
SITUATIONAL
Page 98 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Humana
Search Options
Code
Search Option
*1
Subscriber
*2
Medicare Number
*3
Medicaid Number
Field 1 Search
Subscriber Member
ID
Subscriber Medicare
ID
Subscriber Medicaid
ID
Field 2 Search
Subscriber Birth
Date
Subscriber Birth
Date
Subscriber Birth
Date
Field 3 Search
Subscriber State
Payer Name
Payer Name
Humana
Payer ID ^
00041
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Entity Identifier Code
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Entity Identifier Code
Qualifier
REQUIRED
NM1 Information Source
NM103 – Organization Humana
Organization Name
Name
Name
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Name
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Entity
00041
Carrier ID
Name
Identification Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Entity Identifier
Qualifier
Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Organization
Qualifier
Name
OPTIONAL
Page 99 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Organization
Name
OPTIONAL
NM1 Information
Receiver Provider Tax ID
REQUIRED
NM1 Information
Receiver Provider Tax ID
NM103 – Organization
Name
NM108 – Identification
Code Qualifier
FI
NM109 – Identification
Code
REQUIRED
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
Organization Name
REF01 – Identification
Code Qualifier
Federal Tax ID Number
Federal Tax ID Number
XX
Service Provider NPI
Service Provider NPI
TJ
REF02 – Identification
Code
Service Provider Tax ID
Service Provider Tax ID
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
NM101 – Entity
IL
Subscriber Member ID
Member ID
Identifier Code
*1
NM Subscriber
Member ID
NM102 – Entity Type
Qualifier
1
Person
*1
NM Subscriber
Member ID
NM108 – Identification
Code Qualifier
MI
Subscriber Member ID
*1
NM Subscriber
Member ID
NM109 – Identification
Code
*1
Page 100 of 259
Subscriber Member ID
Member Identification Number:
A hyphen or a space is allowed
in the 10th position. Humana
recommends using the Member
ID number shown on the
members ID card. If
ChoiceCare please provide the
Member ID number including the
2-digit suffix.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Subscriber
Medicare ID
NM101 – Entity Code
Identifier
IL
Subscriber Medicare ID
*2
NM1 Subscriber
Medicare ID
NM102 – Entity Type
Qualifier
1
Person
*2
REF Subscriber
Medicare ID
REF01 – Reference
Identification Qualifier
F6
Subscriber Medicare ID
*2
REF Subscriber
Medicare ID
REF02 – Reference
Identification
*2
NM1 Subscriber
Medicaid ID
NM101 – Entity Code
Identifier
IL
Subscriber Medicaid ID
*3
NM1 Subscriber
Medicaid ID
NM102 – Entity Type
Qualifier
1
Person
*3
NM1 Subscriber
Medicaid ID
REF01 – Reference
Identification Qualifier
NQ
Medicaid Recipient Identification
Number
*3
NM1 Subscriber
Medicaid ID
REF02 – Reference
Identification
*3
DMG Subscriber
Birth Date
Subscriber Medicare ID
Medicaid Recipient Identification
Number
DMG01 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
No future birth date.
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date
No future birth date.
REQUIRED
DMG Subscriber
Birth Date
REQUIRED
N4 Subscriber State
*3
DTP Service Start Date
OPTIONAL
DTP Service Start Date
OPTIONAL
DTP Service Start Date
N402 – State or
Province Code
Subscriber State Code
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format
Qualifier
D8
DTP03 – Service Start
Date
CCYYMMDD
EQ01- Service Type
Code
30
Service Start Date
Required for Subscriber
search.
Service Start Date
Cannot be more than 2 years
prior to the current date or more
than 1 year in the future.
OPTIONAL
Loop 2110C
EQ - Service Type
Code
REQUIRED
Page 101 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Illinois Blue Cross Blue Shield
Search Options
Code
*1
*2
Search
Option
Subscriber 1
Subscriber 2
Field 1 Search
Subscriber Last Name
Dependent Last Name
Field 2 Search
Subscriber First Name
Dependent First Name
Field 3 Search
Subscriber Birth Date
Dependent Birth Date
Payer Name
Payer Name
Illinois Blue Cross Blue Shield
Payer ID ^
ILBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
ILBLS
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
1
Person (Providers)
2
Non-Person Entity (Facility)
Receiver Entity Identifier
Qualifier
Code
REQUIRED
NM1 Information
NM108 – Identification SV
Provider ID
Receiver Service
Code Qualifier
Provider ID
SITUATIONAL
NM1 Information
Receiver Provider ID
NM109 – Identification
Code
Provider ID
7-12 character Provider ID
SITUATIONAL
Page 102 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF02 – Identification
Code
XX
Service Provider NPI
Service Provider NPI
Q4
Service Provider ID
7-12 character Provider ID
Service Provider ID
7-12 character Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
NM108 – Identification MI
Subscriber Member ID
Member ID
Code Qualifier
REQUIRED
NM Subscriber
Member ID
REQUIRED
NM1 Subscriber
Last Name
*1
SITUATIONAL
NM1 Subscriber
First Name
*1
SITUATIONAL
DMG Subscriber
Birth Date
NM109 – Identification
Code
Subscriber Member ID
Enter the 3-character
alpha/numeric prefix.
NM103 – Subscriber
Last Name
NM104 – Subscriber
First Name
DMG02 – Subscriber
Birth Date
CCYYMMDD
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Service Start
Date
D8
CCYYMMDD
Service Start Date
DTP01 – Date/Time
Qualifier
472
Cannot exceed 2 years prior
to current date.
Service End Date
*1
SITUATIONAL
DTP Service Start Date
Service Start Date
OPTIONAL
DTP Service Start Date
OPTIONAL
DTP Service Start Date
OPTIONAL
DTP Service End date
OPTIONAL
Page 103 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110C
EQ - Service Type
Code
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Service End
Date
D8
EQ01- Service Type
Code
30
CCYYMMDD
Service End Date
Cannot exceed 2 years prior
to current date. No future
dates. Required if the
Service Start Date is present.
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent
NM103 – Dependent
Required if patient is the
Dependent.
Last Name
Last Name
*2
SITUATIONAL
NM1 Dependent
First Name
*2
NM104 – Dependent
First Name
SITUATIONAL
DMG Dependent
Birth Date
*2
DMG02 – Dependent
Birth Date
CCYYMMDD
Required if patient is the
Dependent.
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Period Format
Qualifier
D8
DTP03 – Service Start
Date
CCYYMMDD
Service Start Date
DTP01 – Date/Time
Qualifier
472
Cannot exceed 2 years prior
to current date.
Service Start Date
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Service Start
Date
D8
EQ01- Service Type
Code
30
SITUATIONAL
DTP Service Start Date
OPTIONAL
DTP Service Start Date
OPTIONAL
DTP Service Start Date
Required if patient is the
Dependent.
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110D
EQ - Service Type
Code
CCYYMMDD
Service End Date
Cannot exceed 2 years prior
to current date. No future
dates. Required if the
Service Start Date is present.
SITUATIONAL
Page 104 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Illinois Medicaid
Search Options
Code
*1
*2
*3
*4
*5
Search
Field 1
Field 2
Field 3
Option
Search
Search
Search
Subscriber 1
Subscriber Member ID
Subscriber 2
Subscriber SSN
Subscriber Last Name Subscriber First Name
Subscriber 3
Subscriber SSN
Subscriber DOB
Subscriber 4
Subscriber Last Name
Subscriber First Name
Subscriber DOB
Subscriber 5 Subscriber ID Card Number @
Payer Name
Payer Name
Illinois Medicaid
Payer ID
ILMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
ILMCD
Carrier ID
Name Payer ID
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Entity Identifier
Qualifier
REQUIRED
NM1 Information
NM108 – Identification SV
Service Provider Number Receiver ID assigned by the
Receiver Service
Code Qualifier
payer to the provider Service
Provider ID
Provider Number
REQUIRED
NM1 Information
NM109 – Identification
Service Provider Number
Receiver Service
Code
Provider ID
REQUIRED
Page 105 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider ID
SITUATIONAL
XX
Service Provider NPI
Service Provider NPI
Q4
REF02 – Identification
Code
Service Provider ID
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
NM108 – Identification MI
Subscriber Member ID
Member ID
Code Qualifier
*1
NM1 Subscriber
Member ID
NM109 – Identification
Code
*1
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
*2, *4
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
*2, *4
DMG Subscriber
Birth Date
DMG02 – Subscriber
Birth Date
CCMMYYDD
Subscriber Birth Date
REF01 – Reference
Identification Qualifier
SY
Social Security Number
*3, *4
REF Subscriber SSN
*2, *3
REF Subscriber SSN
Subscriber Member ID
First Name or First Initial
REF02 – Reference
Identification Number
*2, *3
REF Subscriber ID Card
Number @
REF01 – Reference
Identification Qualifier
*5
REF Subscriber Card
Control Number @
REF02 - Reference
Identification Number
Social Security Number
HJ
Subscriber ID Card Number
Subscriber ID Card Number
*5
Page 106 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service End Date
REQUIRED
DTP Service End Date
REQUIRED
DTP Service End Date
REQUIRED
Loop 2110C
EQ - Service Type
Code
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Format Qualifier
RD8
Service Date Range
DTP03 – Service Start
Date
CCYYMMDD CCYYMMDD
Service Start Date
DTP01 – Date/Time
Qualifier
472
Service End Date
DTP02 – Date/Time
Format Qualifier
RD8
Service End Date Range
DTP03 – Service End
Date
CCYYMMDD CCYYMMDD
Service End Date
Cannot be more than 1 year
prior to current date. DOS span
cannot exceed 90 days. The
Default value is current date.
Cannot be more than 1 year
prior to current date. DOS span
cannot exceed 90 days. The
Default value is current date.
EQ01- Service Type
Code
REQUIRED
@Indicates that field data may be obtained from card swipe.
Page 107 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Indiana Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Code
*1
*2
Search
Option
Field 1
Search
Subscriber
Subscriber Last Name
Subscriber
Dependent Last Name
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Subscriber
First Name
Subscriber
First Name
Subscriber
DOB
Subscriber
Member ID
Subscriber
Member ID
Dependent
Last Name
Subscriber
Gender
Dependent
First Name
Dependent
DOB
Dependent
Gender
Payer Name
Payer Name
Indiana Blue Cross Blue Shield
Payer ID ^
INBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Name
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Name
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
INBLS
Carrier ID
Name
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
1
Person (Providers)
2
Non-Person Entity (Facility)
Receiver Entity Identifier
Qualifier
Code
REQUIRED
NM1 Information
NM108 – Identification SV
Provider ID
XX
NPI
Receiver Service
Code Qualifier
Provider ID
REQUIRED
NM1 Information
NM109 – Identification
If NM108 is equals SV should
use Provider ID.
Receiver Provider ID
Code
If NM108 is equals XX should
use NPI.
REQUIRED
Page 108 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information
Receiver Service
Provider ID
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
Q4
REF02 – Identification
Code
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
NM108 – Identification MI
Subscriber Member ID
Member ID
Code Qualifier
REQUIRED
NM Subscriber
Member ID
REQUIRED
NM1 Subscriber
Last Name
*1
SITUATIONAL
NM1 Subscriber
First Name
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110C
DTP Eligibility Date
NM109 – Identification
Code
Subscriber Member ID
NM103 – Subscriber
Last Name
Required for Subscriber Search.
NM104 – Subscriber
First Name
Required for Subscriber Search.
DMG01 – Subscriber
Birth Date
D8
Required for Subscriber Search.
DMG02 – Subscriber
Birth Date
CCYYMMDD
Required for Subscriber Search.
DMG03 – Subscriber
Gender Code
M
F
Male
Female
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time
Period Format
Qualifier
RD8
CCYYMMDDCCYYMMDD
Eligibility
OPTIONAL
DTP Eligibility Date
OPTIONAL
Page 109 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Eligibility Date
OPTIONAL
EQ - Service Type
Code
DTP03 – Eligibility
Date
CCYYMMDDCCYYMMDD
EQ01- Service Type
Code
30
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent
NM103 – Dependent
Required for Dependent Search.
Last Name
Last Name
*2
SITUATIONAL
NM1 Dependent
NM104 – Dependent
Required for Dependent Search.
First Name
First Name
*2
SITUATIONAL
DMG Dependent
DMG01 – Dependent
D8
Required for Dependent Search.
Birth Date
Birth Date
*2
SITUATIONAL
DMG Dependent
DMG02 – Dependent
CCYYMMDD
Required for Dependent Search.
Birth Date
Birth Date
*2
SITUATIONAL
DMG Dependent Gender DMG03 – Dependent
M
Male
F
Female
Gender Code
OPTIONAL
DTP Eligibility Date
DTP01 – Date/Time
307
Eligibility
Qualifier
OPTIONAL
DTP Eligibility Date
DTP02 – Date/Time
RD8
Period Format
OPTIONAL
Qualifier
DTP Eligibility Date
DTP03 – Eligibility
CCYYMMDDCCYYMMDD
Date
OPTIONAL
Loop 2110D
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
EQ01- Service Type
Code
30
Eligibility
CCYYMMDDCCYYMMDD
OPTIONAL
EQ - Service Type
Code
SITUATIONAL
Page 110 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Indiana Medicaid
Search Options
Code
*1
*2
*3
*4
Search Option
Subscriber 1
Subscriber 2
Subscriber 3
Subscriber 4
Field 1 Search
Subscriber Member ID
Subscriber SSN
Subscriber Last Name
Subscriber Medicare ID
Field 2 Search
Field 3 Search
Subscriber First Name
Subscriber DOB
Payer Name
Payer Name
Indiana Medicaid
Payer ID
INMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Identifier
Code
REQUIRED
NM1 Information Source
REQUIRED
NM1 Information Source
REQUIRED
NM1 Information Source
Name
REQUIRED
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
INMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Entity Identifier
Qualifier
Code
REQUIRED
NM1 Information
NM108 – Identification SV
Service Provider Number
Receiver Service
Code Qualifier
Provider ID
REQUIRED
NM1 Information
NM109 – Identification
Service Provider Number 9-digit Provider ID plus 1 digit
Receiver Service
Code
location code. (A-Z)
Provider ID
REQUIRED
Page 111 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider ID
SITUATIONAL
XX
Service Provider NPI
Service Provider NPI
Q4
REF02 – Identification
Code
Service Provider ID
Service Provider ID
9-digit Provider ID plus 1 digit
location code. (A-Z)
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
NM108 – Identification MI
Subscriber Member ID
Member ID
Code Qualifier
*1
NM1 Subscriber
Member ID
*1
REF Subscriber
Medicare ID
*4
REF Subscriber
Medicare ID
*4
REF Subscriber SSN
*2
REF Subscriber SSN
NM109 – Identification
Code
REF01 – Reference
Identification Qualifier
Subscriber Member ID 12-digit Recipient ID Number
F6
REF02 - Reference
Identification
REF01 – Reference
Identification Qualifier
Subscriber Medicare ID
Number
Subscriber Medicare ID
Number
SY
REF02 – Reference
Identification Number
Social Security Number
Social Security Number
*2
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
*3
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
*3
DMG Subscriber
Birth Date
DMG02 – Subscriber
Birth Date
CCMMYYDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
307
Eligibility Start Date
*3
DTP Eligibility Start Date
REQUIRED
Page 112 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Eligibility Start Date
DTP02 – Date/Time
Format Qualifier
D8
DTP03 – Eligibility
Start Date
CCYYMMDD
EQ01- Service Type
Code
4, 12, 18, 23, 24, 25,
28, 30, 33, 34, 35, 41,
56, 71, 93, 94, 98, A8,
AB, AD, AE, AF, AI,
AL, AM, AO
REQUIRED
DTP Eligibility Start Date
Eligibility Start Date
REQUIRED
Loop 2110C
EQ - Service Type
Code
REQUIRED
Page 113 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
John Alden Life Insurance Company
Search Options
Code
*1
*2
Search
Option
Subscriber 1
Subscriber 2
Field 1 Search
Subscriber Last Name
Dependent Last Name
Field 2 Search
Subscriber First Name
Dependent First Name
Field 3 Search
Subscriber Birth Date
Dependent Birth Date
Payer Name
Payer Name
John Alden Life Insurance Company
Payer ID ^
41099
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Entity Identifier Code
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Entity Identifier Code
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification 41099
Carrier ID
Name Payer ID
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Entity Identifier
Qualifier
REQUIRED
NM1 Information
NM108 – Identification FI
Federal Tax ID Number
Receiver Provider Tax ID Code Qualifier
SITUATIONAL
NM1 Information
NM109 – Identification
Federal Tax ID Number
Receiver Provider Tax ID Code
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
SITUATIONAL
Page 114 of 259
NM108 – Identification
Code Qualifier
XX
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Service
Provider NPI
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
NM109 – Identification
Code
REF01 – Identification
Code Qualifier
Service Provider NPI
TJ
REF02 – Identification
Code
Service Provider Tax ID
Service Provider Tax ID
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
NM108 – Identification MI
Member Policy Number.
Member ID
Code Qualifier
Carrier will only accept upper
case letters.
REQUIRED
NM Subscriber
Member ID
NM109 – Identification
Code
Member Policy Number.
REQUIRED
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
Carrier will only accept upper
case letters.
*1
NM1 Subscriber
First Name
NM103 – Subscriber
First Name
Carrier will only accept upper
case letters.
*1
REF Subscriber SSN
REF01 – Reference
Identification Qualifier
Carrier will only accept upper
case letters.
SY
OPTIONAL
REF Subscriber SSN
REF02 – Reference
Identification
Social Security Number
Carrier recommends using this
field to improve matching.
OPTIONAL
DMG Subscriber
Birth Date
*1
DTP Eligibility Start Date
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
307
Eligibility Start Date
Required for Subscriber
search.
DTP02 – Date/Time
Period Format
Qualifier
D8
DTP03 – Eligibility
Start Date
CCYYMMDD
SITUATIONAL
DTP Eligibility Start Date
SITUATIONAL
DTP Eligibility Start Date
SITUATIONAL
Eligibility Start Date
Required for Subscriber
search.
Loop 2110C
Page 115 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
EQ - Service Type
Code
EQ01- Service Type
Code
30
Required for Subscriber
search.
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM Dependent
NM103 – Last Name
Patient Last Name
Carrier recommends using this
Last Name
field to improve matching.
*2
NM Dependent
First Name
NM104 – First Name
Patient First Name
Carrier recommends using this
field to improve matching.
*2
NM Dependent
Birth Date
DMG02 – Dependent
Birth Date
CCYYMMDD
Patient Birth Date
DTP01 – Date/Time
Qualifier
307
Eligibility Start Date
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Start Date
D8
EQ01- Service Type
Code
30
*2
DTP Eligibility Start Date
Required for Dependent
search.
SITUATIONAL
DTP Eligibility Start Date
SITUATIONAL
DTP Eligibility Start Date
CCYYMMDD
Required for Dependent
search.
SITUATIONAL
Loop 2110D
EQ - Service Type Code
Eligibility Start Date
SITUATIONAL
Service Type Code
Required for Dependent
search.
Page 116 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Kaiser Foundation Health Plan of Ohio
Search Options
Code
*1
*2
*3
Search Option
Subscriber 1
Subscriber 2
Subscriber 3
Field 1 Search
Subscriber Member ID
Subscriber SSN
Subscriber Gender
Payer Name
Payer Name
Kaiser Foundation Health Plan of Ohio
Payer ID ^
00280
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Entity Identifier Code
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Entity Identifier Code
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification 00280
Carrier ID
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier Identifier Code
REQUIRED
NM1 Information
NM102 – Entity Type
1
Person
2
Non-Person Entity
Receiver Entity Identifier Qualifier
REQUIRED
NM1 Information
NM108 – Identification
FI
Federal Tax ID Number
Receiver Provider TIN
Code Qualifier
SITUATIONAL
NM1 Information
NM109 – Identification
Federal Tax ID Number
Receiver Provider TIN
Code
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
Page 117 of 259
NM108 – Identification
Code Qualifier
NM109 – Identification
Code
XX
Service Provider NPI
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF02 – Identification
Code
TJ
Service Provider Tax ID
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
NM103 – Subscriber
Last Name
Last Name
REQUIRED
NM1 Subscriber
First Name
REQUIRED
NM Subscriber
Member ID
*1
NM Subscriber
Member ID
*1
REF Subscriber SSN
*2
REF Subscriber SSN
*2
DMG Subscriber
Birth Date
REQUIRED
DMG Subscriber
Birth Date
REQUIRED
DMG Subscriber Gender
*3
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
Loop 2110C
EQ - Service Type
Code
NM104 – Subscriber
First Name
NM108 – Identification
Code Qualifier
MI
NM109 – Identification
Code
Subscriber Member ID
Subscriber Member ID
REF01 – Reference
Identification Qualifier
REF02 – Reference
Identification
SY
DMG01 – Date/Time
Period Format
Qualifier
DMG02 – Subscriber
Birth Date
D8
Subscriber Birth Date
CCYYMMDD
Subscriber Birth Date
DMG03 –Gender
Code
DTP01 – Date/Time
Qualifier
F = Female
M = Male
307
Service Start Date
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Service Start
Date
D8
EQ01- Service Type
Code
30
Social Security Number
Social Security Number
Service Start Date
REQUIRED
Page 118 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Kentucky Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Code
*1
*2
Search
Option
Field 1
Search
Subscriber
Subscriber Last Name
Subscriber
Dependent Last Name
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Subscriber
First Name
Subscriber
First Name
Subscriber
DOB
Subscriber
Member ID
Subscriber
Member ID
Dependent
Last Name
Subscriber
Gender
Dependent
First Name
Dependent
DOB
Dependent
Gender
Payer Name
Payer Name
Kentucky Blue Cross Blue Shield
Payer ID ^
KYBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
KYBLS
Carrier ID
REQUIRED
NM1 Information Source
Name
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
1
Person (Providers)
2
Non-Person Entity (Facility)
Receiver Entity Identifier
Qualifier
Code
REQUIRED
NM1 Information
NM108 – Identification SV
Provider ID
XX
NPI
Receiver Service
Code Qualifier
Provider ID
REQUIRED
Page 119 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Provider ID
NM109 – Identification
Code
REQUIRED
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF02 – Identification
Code
Q4
If NM108 is equals SV should
use Provider ID.
If NM108 is equals XX should
use NPI.
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
NM108 – Identification MI
Subscriber Member ID
Member ID
Code Qualifier
REQUIRED
NM Subscriber
Member ID
REQUIRED
NM1 Subscriber
Last Name
*1
SITUATIONAL
NM1 Subscriber
First Name
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110C
DTP Eligibility Date
NM109 – Identification
Code
Subscriber Member ID
NM103 – Subscriber
Last Name
Required for Subscriber Search.
NM104 – Subscriber
First Name
Required for Subscriber Search.
DMG01 – Subscriber
Birth Date
D8
DMG02 – Subscriber
Birth Date
CCYYMMDD
Required for Subscriber Search.
Required for Subscriber Search.
DMG03 – Subscriber
Gender Code
M
F
Male
Female
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
DTP01 – Date/Time
Qualifier
307
Date expressed as
CCYYMMDD.
CCYYMMDDCCYYMMDD
Eligibility
OPTIONAL
Page 120 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
EQ - Service Type
Code
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
EQ01- Service Type
Code
30
CCYYMMDDCCYYMMDD
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent
NM103 – Dependent
Required for Dependent Search.
Last Name
Last Name
*2
SITUATIONAL
NM1 Dependent
NM104 – Dependent
Required for Dependent Search.
First Name
First Name
*2
SITUATIONAL
DMG Dependent
DMG01 – Dependent
D8
Date expressed as
CCYYMMDD.
Birth Date
Birth Date
*2
Required for Dependent Search.
SITUATIONAL
DMG Dependent
Birth Date
*2
SITUATIONAL
DMG Dependent Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110D
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
EQ - Service Type
Code
DMG02 – Dependent
Birth Date
CCYYMMDD
Required for Dependent Search.
DMG02 – Dependent
Gender Code
M
F
Male
Female
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
EQ01- Service Type
Code
30
CCYYMMDDCCYYMMDD
Eligibility
CCYYMMDDCCYYMMDD
SITUATIONAL
Page 121 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Louisiana Blue Cross Blue Shield
Search Options Not Applicable.
Payer Name
Payer Name
Louisiana Blue Cross Blue Shield
Payer ID
LABLS
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM1 Information Source
Name
REQUIRED
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
LABLS
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Name
Identifier Code
REQUIRED
NM1 Information
NM102 – Entity Type
2
Non-Person Entity
Receiver Name
Qualifier
REQUIRED
NM1 Information
NM108 – Identification SV
Service Provider Number
Receiver Service
Code Qualifier
Provider ID
SITUATIONAL
NM1 Information
Receiver Service
Provider ID
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
NM108 – Identification
Code Qualifier
Service Provider Number
XX
Service Provider NPI
SITUATIONAL
Page 122 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF02 – Identification
Code
Service Provider NPI
Q4
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Loop 2100C
NM1 Subscriber
Member ID
Reference
Designator(s)
Value
Definitions and Notes Specific
to ICS
NM108 – Identification
Code Qualifier
MI
Subscriber Member ID
REQUIRED
NM1 Subscriber
Member ID
NM109 – Identification
Code
Subscriber Member ID
NM104 – Subscriber
First Name
Subscriber First Name
REQUIRED
NM1 Subscriber
First Name
OPTIONAL
DMG Subscriber
Birth Date
DMG02 – Subscriber
Birth Date
CCMMYYDD
Subscriber Birth Date
DMG03 – Gender
Code
F = Female
M = Male
Subscriber Gender Code
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Format Qualifier
D8
DTP03 – Service Start
Date
CCYYMMDD
REQUIRED
DMG Subscribe Gender
OPTIONAL
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
Service Start Date
REQUIRED
Loop 2110C
EQ - Service Type
Code
EQ01- Service Type
Code
REQUIRED
Page 123 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Louisiana Medicaid
Search Options
Code
Search Option
*1
Subscriber 1
*2
Subscriber 2
*3
Subscriber 3
Field 1 Search
Subscriber Member
ID
Subscriber Member
ID
Subscriber Member
ID
*4
Subscriber 4
Subscriber SSN
*5
Subscriber 5
*6
Subscriber 6
*7
Subscriber 7
*8
Subscriber 8
Subscriber SSN
Subscriber Last
Name
Subscriber ID Card
Number @
Subscriber ID Card
Number @
Field 2 Search
Subscriber SSN
Subscriber Last
Name
Subscriber Birth
Date
Subscriber Last
Name
Subscriber Birth
Date
Subscriber First
Name
Subscriber Card
Issue Date @
Subscriber Card
Issue Date @
Field 3 Search
Subscriber First
Name
Subscriber First
Name
Subscriber Birth
Date
Subscriber SSN
Subscriber Birth
Date
Payer Name
Payer Name
Louisiana Medicaid
Payer ID
LAMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Loop 2100A
NM1 Information Source
Entity Identifier Code
REQUIRED
NM1 Information Source
Entity Identifier Code
REQUIRED
NM1 Information
Receiver Source ID
REQUIRED
NM1 Information
Receiver Source ID
REQUIRED
Reference
Designator(s)
Value
Definitions and Notes Specific
to ICS
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
PI
Payer Identification
NM109 – Identification
Code
LAMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Designator(s)
Value
Definitions and Notes Specific
to ICS
Loop 2100B
Page 124 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM101 - Entity
Identifier Code
1P
Provider
First position must be a 1.
NM1 Information
Receiver Entity Identifier
Code
REQUIRED
NM1 Information
Receiver Service
Provider ID
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
SV
Service Provider Number
SITUATIONAL
NM1 Information
Receiver Service
Provider ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF02 – Identification
Code
Service Provider Number
XX
Service Provider NPI
Service Provider NPI
Q4
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber
NM108 – Identification MI
Subscriber Member ID
Member ID
Code Qualifier
*1, *2, *3
NM1 Subscriber
Member ID
NM109 – Identification
Code
*1, *2, *3
REF Subscriber
ID Card Number
REF01 – Reference
Identification Qualifier
*7, *8
REF Subscriber
ID Card Number
REF02 - Reference
Identification
Subscriber Member ID
HJ
Card Control Number
Card Control Number
*7, *8
Page 125 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Subscriber
Card Issue Date @
DTP01 – Date/Time
Qualifier
102
DTP02 – Date/Time
Period Format
Qualifier
D8
DTP03 – Subscriber
Card Issue Date
CCYYMMDD
Card Issue Date
REF01 – Reference
Identification Qualifier
SY
Social Security Number
Card Issue Date
*7, *8
DTP Subscriber
Card Issue Date @
*7, *8
DTP Subscriber
Card Issue Date @
*7, *8
REF Subscriber SSN
*1, *4, *5, *7
REF Subscriber SSN
REF02 – Reference
Identification
*1, *4, *5, *7
NM1 Subscriber
Last Name
NM103 – Subscriber
Last Name
Social Security Number
*2, *4, *6
NM1 Subscriber
First Name
NM104 – Subscriber
First Name
*2, *4, *6
DMG Subscriber
Birth Date
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date –
Cannot be prior to 1875
DTP01 – Date/Time
Qualifier
472
Service Date
DTP02 – Date/Time
Period Format
Qualifier
D8
CCYYMMDD
DTP03 – Service Start
Date
CCYYMMDD
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
Service Start Date
Cannot Be more than 12 moths
prior to current date.
Future dates cannot be more
than the last date of current
month. No date spans.
Loop 2110C
EQ - Service Type
Code
EQ01- Service Type
Code
REQUIRED
@Indicates field data may be obtained from the card swipe.
Page 126 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Maine Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Code
*1
*2
Search
Option
Member ID
Member ID
Field 1 Search
Subscriber First Name
Dependent First Name
Field 2 Search
Subscriber Last Name
Dependent Last Name
Field 3 Search
Subscriber Date of Birth
Dependent Date of Birth
Payer Name
Payer Name
Maine Blue Cross Blue Shield
Payer ID ^
MEBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Name
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Name
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Name
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
MEBLS
Carrier ID
Name
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
Code
REQUIRED
NM1 Information
NM102 – Entity Type
1
Person (Providers)
2
Non-Person Entity (Facility)
Receiver Entity Identifier
Qualifier
Code
REQUIRED
NM1 Information
NM108 – Identification SV
Provider ID
XX
NPI
Receiver Service
Code Qualifier
Provider ID
REQUIRED
NM1 Information
Receiver Provider ID
REQUIRED
Page 127 of 259
NM109 – Identification
Code
If NM108 is equals SV should
use Provider ID.
If NM108 is equals XX should
use NPI.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information
Receiver Service
Provider ID
SITUATIONAL
REF Information
Receiver Service
Provider ID
REF01 – Identification
Code Qualifier
Q4
REF02 – Identification
Code
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
NM108 – Identification MI
Subscriber Member ID
Member ID
Code Qualifier
REQUIRED
NM Subscriber
Member ID
REQUIRED
NM1 Subscriber
Last Name
*1
SITUATIONAL
NM1 Subscriber
First Name
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber
Birth Date
*1
SITUATIONAL
DMG Subscriber Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110C
DTP Eligibility Date
NM109 – Identification
Code
Subscriber Member ID
NM103 – Subscriber
Last Name
Required for Subscriber Search.
NM104 – Subscriber
First Name
Required for Subscriber Search.
DMG01 – Subscriber
Birth Date
D8
Required for Subscriber Search.
DMG02 – Subscriber
Birth Date
CCYYMMDD
Required for Subscriber Search.
DMG03 – Subscriber
Gender Code
M
F
Male
Female
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
DTP01 – Date/Time
Qualifier
307
CCYYMMDDCCYYMMDD
Eligibility
OPTIONAL
Page 128 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
EQ - Service Type
Code
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
EQ01- Service Type
Code
30
CCYYMMDDCCYYMMDD
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Loop 2100D
NM1 Dependent
Last Name
*2
SITUATIONAL
Reference
Designator(s)
Value
Definitions and Notes Specific
to ICS
NM103 – Dependent
Last Name
Required for Dependent Search.
NM1 Dependent
First Name
*2
SITUATIONAL
DMG Dependent
Birth Date
*2
SITUATIONAL
NM104 – Dependent
First Name
Required for Dependent Search.
DMG01 – Dependent
Birth Date
D8
Required for Dependent Search.
DMG Dependent
Birth Date
*2
SITUATIONAL
DMG02 – Dependent
Birth Date
CCYYMMDD
Required for Dependent Search.
DMG Dependent Gender
DMG02 – Dependent
Gender Code
M
F
Male
Female
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Date
RD8
EQ01- Service Type
Code
30
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110D
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
EQ - Service Type
Code
CCYYMMDDCCYYMMDD
Eligibility
CCYYMMDDCCYYMMDD
SITUATIONAL
Page 129 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
MAHP/MAMSI
Search Options
Code
*1
*2
Search Option
Subscriber 1
Subscriber 2
Field 1 Search
Subscriber Member ID
Subscriber SSN
Payer Name
Payer Name
MAHP/MAMSI
Payer ID
52148
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity
PR
Payer
Identifier Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
52148
Carrier ID
Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information
NM101 - Entity
1P
Provider
Receiver Entity Identifier
Identifier Code
REQUIRED
NM1 Information
Receiver Entity Identifier
REQUIRED
NM1 Information
Receiver Provider Tax ID
REQUIRED
NM1 Information
Receiver Provider Tax ID
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
FI
Federal Tax ID
NM109 – Identification
Code
REQUIRED
NM1 Information
Receiver Service
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information
Receiver Service
Provider NPI
NM109 – Identification
Code
Federal Tax ID
XX
Service Provider NPI
Service Provider NPI
SITUATIONAL
Page 130 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information
Receiver Service
Provider Tax ID
SITUATIONAL
REF Information
Receiver Service
Provider Tax ID
REF01 – Identification
Code Qualifier
TJ
REF02 – Identification
Code
Service Provider Tax ID
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
NM108 – Identification MI
MA Medicaid Recipient ID.
Member ID
Code Qualifier
*1
NM Subscriber
Member ID
*1
REF Subscriber SSN
*2
REF Subscriber SSN
*2
DTP Eligibility Start Date
NM109 – Identification
Code
MA Medicaid Recipient ID.
The last seven characters must
be numeric.
REF01 – Reference
Identification Qualifier
MA Medicaid Recipient ID.
The last seven characters must
be numeric.
REF02 – Reference
Identification
MA Medicaid Recipient ID.
The last seven characters must
be numeric.
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format
Qualifier
DTP03 – Eligibility
Start Date
D8
EQ01- Service Type
Code
30
Service Start Date
REQUIRED
DTP Eligibility Start Date
REQUIRED
DTP Eligibility Start Date
CCYYMMDD
REQUIRED
Loop 2110C
EQ - Service Type
Code
Service Start Date
The default value is the current
date.
REQUIRED
Page 131 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Massachusetts Blue Cross Blue Shield
Search Options Not Applicable.
Payer Name
Payer Name
Massachusetts Blue Cross Blue Shield
Payer ID ^
00139
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Segment
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
00139
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
NM101 - Entity Identifier
Code
1P
FA
Provider
Facility
REQUIRED
NM1 Information Receiver
Entity Identifier Code
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
SITUATIONAL
NM1 Information Receiver
Service Provider ID
NM108 – Identification
Code Qualifier
SV
Provider ID
6 character Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
Provider ID
Either 6-character Provider ID or
10-character Facility ID is
required.
XX
Service Provider NPI
Service Provider NPI
SITUATIONAL
Page 132 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Service Provider ID
REF01 – Identification
Code Qualifier
SITUATIONAL
REF Information Receiver
Service Provider ID
REF02 – Identification
Code
Q4
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber
Member ID
NM108 – Identification
Code Qualifier
REQUIRED
NM Subscriber
Member ID
NM109 – Identification
Code
Subscriber Member ID
REQUIRED
NM1 Subscriber
Last Name
NM103 – Subscriber Last
Name
Optional for BCBS of MA
member.
NM104 – Subscriber First
Name
Use only if patient is the
Subscriber.
Optional for BCBS of MA
member.
SITUATIONAL
NM1 Subscriber
First Name
SITUATIONAL
DMG Subscriber Birth Date
MI
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
Loop 2110C
EQ - Service Type Code
Use only if patient is the
Subscriber.
Subscriber Birth Date
Required if patient is the
Subscriber and the member is a
non- BCBS MA Subscriber.
DMG02 – Subscriber Birth
Date
CCYYMMDD
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format Qualifier
D8
DTP03 – Service Start
Date
CCYYMMDD
Service Start Date
Required for Subscriber search.
EQ01- Service Type Code
See below table
Default value is
30.
Required for Subscriber search.
SITUATIONAL
DTP Service Start Date
Subscriber Member ID
REQUIRED
Service Start Date
BCBS MA accepts all valid
values that are not on the
below table and will process
them as a 30.
Service Type Codes currently supported by BCBS MA (continues on next page)
Code
1
2
4
5
Page 133 of 259
Name
Medical Care
Surgical
Diagnostic X-ray
Diagnostic Lab
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
6
7
12
13
17
18
20
23
24
25
26
30
33
35
36
38
39
40
41
42
45
48
50
52
53
56
62
65
66
68
Radiation Therapy
Anesthesia
Durable Medical Equipment Purchase
Ambulatory Service Center Facility
Pre-admission Testing
Durable Medical Equipment Rental
Second Surgical Opinion
Diagnostic Dental
Periodontics
Restorative
Endodontics
Health Benefit Plan Coverage – If only a single category of inquiry can be supported, use
this code.
Chiropractic
Dental Care
Dental Crowns
Orthodontics
Prosthodontics
Oral Surgery
Routine (Preventive) Dental
Home Health Care
Hospice
Hospital – Inpatient
Hospital – Outpatient
Hosptial – Emergency Medical
Hospital – Ambulatory Surgical
Medically Related Transportation
MRI/CAT Scan
Newborn Care
Patholgy
Well Baby Care
Code
69
71
72
75
76
77
78
81
82
83
86
88
93
98
99
A0
Name
Maternity
Audiology Exam
Inhalation Therapy
Prosthetic Device
Dialysis
Otological Exam
Chemotherapy
Routine Physical
Family Planning
Infertility
Emergency Services
Pharmacy
Podiatry
Professional (Physician) Visit – Office
Professional (Physician) Visit – Inpatient
Professional (Physician) Visit – Outpatient
Page 134 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Psychiatric – Inpatient
Psychiatric – Outpatient
Rehabilitation – Inpatient
Occupational Therapy
Physical Medicine
Speech Therapy
Skilled Nursing Care
Alcoholism
Drug Addiction
Vision (Optometry)
Pulmonary Rehabilitation
Cardiac Rehabilitation
Pediatric
A7
A8
AB
AD
AE
AF
AG
AJ
AK
AL
BF
BG
BH
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM Dependent
Last Name
NM103 – Dependent Last
Name
Required if patient is the
Dependent.
NM104 – Dependent First
Name
Optional if patient is a BCBS
MA member.
Required if patient is the
Dependent.
SITUATIONAL
NM Dependent
First Name
SITUATIONAL
NM Dependent
Birth Date
DMG02 – Dependent Birth
Date
CCYYMMDD
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time
Period Format Qualifier
D8
DTP03 – Service Start
Date
CCYYMMDD
Subscriber Birth Date
Required if patient is the
Subscriber and the member is a
non- BCBS MA Subscriber or if
14-character ID suffix is not
given.
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
Optional if patient is a BCBS
MA member.
Dependent Birth Date
Service Start Date
Required for Dependent
search.
SITUATIONAL
DTP Service Start Date
SITUATIONAL
Loop 2110D
EQ - Service Type Code
SITUATIONAL
Page 135 of 259
Service Start Date
Required for Dependent search.
EQ01- Service Type Code
See above table
Default value is
30.
Required for Dependent search.
BCBS MA accepts all valid
values that are not on the below
table and will process them as a
30.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Massachusetts Medicaid
Search Options
Code
*1
*2
Search
Option
Subscriber 1
Subscriber 2
*3
Subscriber 3
Field 1 Search
Field 2 Search
Field 3 Search
Field 4 Search
Subscriber Member ID
Subscriber Last Name Subscriber First Name Subscriber DOB Subscriber Gender
Subscriber ID Card
Serial Number @
Payer Name
Payer Name
Massachusetts Medicaid
Payer ID
MAMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
MAMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver Entity
Identifier Code
REQUIRED
NM1 Information Receiver Entity
Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
NM101 - Entity Identifier
Code
1P
Provider
First position must be a 1.
NM102 – Entity Type
Qualifier
1
2
Person
Non-Person Entity
NM108 – Identification
Code Qualifier
SV
Provider Medicaid ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
Provider Medicaid ID
XX
Service Provider NPI
SITUATIONAL
Page 136 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver User
ID
REQUIRED
REF Information Receiver User
ID
REQUIRED
REF Information Receiver PIN
REQUIRED
REF Information Receiver PIN
NM109 – Identification
Code
REF01 – Identification
Code Qualifier
Service Provider NPI
Q4
REF02 – Identification
Code
REF01 – Reference
Identification Qualifier
Service Provider ID
JD
REF02 – Reference
Identification
REF01 – Reference
Identification Qualifier
Service Provider ID
User Identification
User Identification
4A
REF02 – Reference
Identification
Personal Identification Number
(PIN)
Personal Identification Number
(PIN)
REQUIRED
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Entity Code
REQUIRED
NM1 Subscriber Type Qualifier
REQUIRED
NM1 Subscriber Last Name
*2
NM1 Subscriber First Name
*2
NM Subscriber Member ID
*1
NM Subscriber Member ID
NM101 – Entity Identifier
Code
IL
Insured or Subscriber
NM102 – Identification
Code
1
Person
NM103 – Subscriber Last
Name
MA Medicaid only uses the first
five characters.
NM104 – Subscriber First
Name
MA Medicaid only uses the first
five characters.
NM108 – Identification
Code Qualifier
MI
NM109 – Identification
Code
MA Medicaid Recipient ID.
GH
The last seven characters must
be numeric.
Subscriber ID Card Serial Num
CCYYMMDD
Subscriber ID Card Serial Num
10-digit Mass Health card
number & 2-digit sequence
number.
Subscriber Birth Date
*1
REF Subscriber
ID Card Serial Number
REF01 – Reference
Identification Qualifier
*3
REF Subscriber
ID Card Serial Number
REF02 – Reference
Identification
*3
DMG Subscriber Birth Date
DMG02 – Subscriber Birth
Date
MA Medicaid Recipient ID.
*2
Page 137 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DMG Subscriber Gender Code
*2
DTP Eligibility Start Date
REQUIRED
DTP Eligibility Start Date
REQUIRED
DTP Eligibility Start Date
DMG03 – Gender Code
F = Female
M = Male
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time
Period Format Qualifier
D8
CCYYMMDD
DTP03 – Eligibility Start
Date
Eligibility Start Date
Cannot be more than 6 months
prior to current date. No future
dates.
REQUIRED
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
Eligibility Start Date
30
REQUIRED
Change “Information Receiver UPIN” to “Information Receiver Personal ID Number” 6/19/06^
Page 138 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Medica Health Plans
Search Options
Search
Option
Field 1
Search
Subscriber 1
Subscriber
Policy
Number
Code
*1
*2
Subscriber 2
*3
Subscriber 3
*4
Dependent 4
*5
Dependent 5
Subscriber
Member ID
Subscriber
Last Name
Subscriber
Member ID
Dependent
Last Name
Field 2
Search
Subscriber
Group
Number
Subscriber
First Name
Subscriber
Group
Number
Dependent
First Name
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Subscriber
Last Name
Subscriber
DOB
Subscriber
First Name
Subscriber
State
Subscriber
DOB
Subscriber
City
Subscriber
Zip
Subscriber
Gender
Dependent
Last Name
Dependent
DOB
Dependent
First Name
Dependent
State
Dependent
DOB
Dependent
City
Dependent
Zip
Dependent
Gender
Payer Name
Payer Name
Medica
Payer ID
94265
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM1 Information Source
Payer ID
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
94265
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
NM101 - Entity Identifier
code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
Page 139 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Entity Identifier Code
NM102 – Entity Type
Qualifier
SITUATIONAL
NM1 Information Receiver
Organization Name
NM103 – Organization
Name
Organization Name
SITUATIONAL
NM1 Information Receiver
First Name
NM103 – First Name
Service Provider First Name
SITUATIONAL
NM1 Information Receiver
First Name
NM104 – First Name
Service Provider First Name
SITUATIONAL
NM1 Information Receiver
Provider ID
SITUATIONAL
NM1 Information Receiver
Provider ID
NM108 – Identification Code
Qualifier
1
SV
NM109 – Identification Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information Receiver
Service Provider ID
REF01 – Identification Code
Qualifier
SITUATIONAL
REF Information Receiver
Service Provider ID
REF02 – Identification Code
Person
Service Provider ID
Service Provider ID
XX
Service Provider ID, Tax ID, or
NPI is required.
Service Provider ID, Tax ID, or
NPI is required.
Q4
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Last Name
*2, *3
NM1 Subscriber First Name
NM104 – First Name
*2, *3
NM1 Subscriber Member ID
*2, *4
NM1 Subscriber Member ID
NM108 – Identification Code
Qualifier
NM109 – Identification Code
MI
Subscriber Member ID
Subscriber Member ID
*2, *4
Page 140 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Subscriber Policy Number
*1
REF Subscriber Policy Number
REF01 – Reference
Identification Qualifier
IG
REF02 – Reference
Identification
Subscriber Policy Number
Subscriber Policy Number
*1
REF Subscriber
Group Number
REF01 – Reference
Identification Qualifier
*2
REF Subscriber
Group Number
REF02 – Reference
Identification
Subscriber Group Number
*2
N4 Subscriber City Name
NM401 – City Name
Subscriber City Name
NM402 – State or Province
Code
Subscriber State Code
NM403 – Postal Code
Subscriber Postal Code
*3
N4 Subscriber State Code
6P
Subscriber Group Number
*3
NM Subscriber Postal Code
*3
DMG Subscriber Birth Date
*2, *3
DMG Subscriber Birth Date
DMG01 – Date/Time Period
Format Qualifier
D8
DMG02 – Subscriber Birth
Date
CCYYMMDD
DMG03 – Subscriber
Gender Code
F = Female
M = Male
EQ03 – Benefit Coverage
Level Code
Refer to the 270
HIPAA
Implementation
Guide for
applicable
qualifiers.
Refer to the 270
HIPAA
Implementation
Guide for
applicable
qualifiers.
307,435 or 472
Benefit Coverage Level
Code
DTP02 – Date/Time Period
Format Qualifier
RD8 or D8
Service Date Range or
Date Qualifier
DTP03 – Date Time Period
CCYYMMDD –
CCYYMMDD
or
CCYYMMDD
Service Date Range or
Date
Subscriber Birth Date
*2, *3
DMG Subscriber Gender
*3
Loop 2110C
EQ Coverage Level Code
OPTIONAL
EQ Insurance Type Code
EQ04 – Insurance Type
Code
OPTIONAL
DTP Subscriber Benefit
Eligibility/Benefit Date
DTP01 – Date/Time
Qualifier
Insurance Type Code
Date Time Qualifier
REQUIRED
DTP Subscriber Benefit
Eligibility/Benefit Date
REQUIRED
DTP Subscriber Benefit
Eligibility/Benefit Date
REQUIRED
Page 141 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
NM103 – Last Name
*4, *5
NM1 Dependent First Name
NM104 – First Name
*4, *5
N4 Dependent City Name
N401 – City Name
Dependent City Name
NM402 – State or Province
Code
Dependent State Code
NM403 – Postal Code
Dependent Postal Code
*5
N4 Dependent State Code
*5
N4 Dependent Postal Code
*5
DMG Dependent Birth Date
DMG01 – Date/Time Period
Format Qualifier
D8
CCYYMMDD
Dependent Birth Date
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
DMG03 – Gender Code
F = Female
M = Male
Dependent Gender Code
EQ03 – Coverage Level
Code
Refer to the 270
HIPAA
Implementation
Guide for
applicable
qualifiers.
Refer to the 270
HIPAA
Implementation
Guide for
applicable
qualifiers.
307,435 or 472
Benefit Coverage Level
Code
DTP02 – Date/Time Period
Format Qualifier
RD8 or D8
Service Date Range or
Date Qualifier
DTP03 – Date Time Period
CCYYMMDD –
CCYYMMDD
or
CCYYMMDD
Service Date Range or
Date
*4, *5
DMG Dependent Birth Date
*4, *5
DMG Dependent Gender
*5
Loop 2110D
EQ Benefit Coverage Level
Code
OPTIONAL
EQ Insurance Type Code
EQ04 – Insurance Type
Code
OPTIONAL
DTP Dependent Benefit
Eligibility/Benefit Date
DTP01 – Date/Time
Qualifier
Insurance Type Code
Date Time Qualifier
REQUIRED
DTP Dependent Benefit
Eligibility/Benefit Date
REQUIRED
DTP Dependent Benefit
Eligibility/Benefit Date
REQUIRED
Page 142 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Medical Mutual of Ohio
Search Options
Code
Search
Option
*1
Subscriber 1
*2
Subscriber 2
*3
Dependent 1
Field 1 Search
Subscriber
Member ID
Subscriber
Group Number
Subscriber
Member ID
Field 2 Search
Subscriber DOB
Subscriber
First Name
Dependent DOB
Field 4
Search
Field 3 Search
Subscriber
Last Name
Dependent
First Name
Subscriber
DOB
Payer Name
Payer Name
Medical Mutual of Ohio
Payer ID
29076
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
29076
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider Number
NM109 – Identification
Code
Service Provider Number
SITUATIONAL
Page 143 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information Receiver
Service Provider ID
REF01 – Identification Code
Qualifier
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
XX
Service Provider NPI
Service Provider NPI
Q4
REF02 – Identification Code
Service Provider ID
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*2
NM1 Subscriber First Name
*2
NM Subscriber Member ID @
*1, *3
NM Subscriber Member ID @
NM103 – Subscriber Last
Name
Only use Subscriber Last
Name for *2 search.
NM104 – Subscriber First
Name
Only use Subscriber First
Name for *2 search.
NM101 – Entity Identifier
Code
MI
NM102 – Entity Type
Qualifier
*1, *3
REF Subscriber
Group Number
REF01 – Reference
Identification Qualifier
*2
REF Subscriber
Group Number
REF02 – Reference
Identification
Subscriber Member ID
Subscriber Member ID
Number
6P
Group Number
Group Number
*2
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
472
Service Date
Required for Subscriber
search.
DTP02 – Date/Time Period
Format Qualifier
D8
SITUATIONAL
DTP Service Start Date
DTP03 – Service Start Date
CCYYMMDD
SITUATIONAL
Loop 2110C
EQ - Service Type Code
Service Start Date
Required for Subscriber
search.
EQ01- Service Type Code
1, 30, 35, AL
Required for Subscriber
search.
DMG Subscriber Birth Date
*1, *2
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
Page 144 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100D
NM Dependent First Name
*3
NM Dependent Birth Date
*3
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
NM104 – Dependent First
Name
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
CCYYMMDD
DTP03 – Service Start Date
Service Start Date
Required for Dependent
search.
SITUATIONAL
Loop 2110D
EQ - Service Type Code
SITUATIONAL
Page 145 of 259
EQ01- Service Type Code
1, 30, 35, AL
Required for Dependent
search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Medicare – Applies to all states and the 10 U.S. Territories.
(American Samoa, District of Columbia, Federated States of Micronesia, Guam, Marshall Islands,
Northern Mariana Islands, Palau, Puerto Rico, U.S. Minor Outlying Islands, and the U.S. Virgin
Islands)
CMS Medicare rules require the use of a valid and registered National Provider Identifier (NPI). INGENIX is
now enforcing this requirement. Please make sure you register your NPI with CMS Medicare and INGENIX prior
to submission of Eligibility Transactions.
Search Options
Code
*1
Search
Option
Field 1 Search
Patient Medicare Number (HIC
Subscriber 1
number or RRB number)
Field 2
Search
Patient’s
First Name
Field 3 Search
Patient’s
Last Name
Field 4
Search
Patient’s DOB
Payer Name
Payer Name
Medicare
Payer ID
CSMEL
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source
Organization Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM103 – Organization
Name
CMS
Organization Name must be
CMS
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
CMSEL
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Medicare Provider Number
NM108 – Identification
Code Qualifier
REQUIRED
NM1 Information Receiver
Medicare Provider Number
NM109 – Identification
Code
XX- NPI
Must submit a CMS registered
Provider NPI.
If NM108 is equal to XX, the
NM109 must be the CMS
registered 10 digit NPI.
REQUIRED
Page 146 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Additional Information
SITUATIONAL
REF Information Receiver
Additional Information
SITUATIONAL
REF01 – Identification Code
Qualifier
1C – Medicare
Provider Number
REF02 – Identification Code
Medicare Provider Number.
If REF01 is equal to 1C, the
REF02 must be the Medicare
Provider Number.
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Subscriber Last
Name
Patient Last Name
NM104 – Subscriber First
Name
Patient First Name
Enter the Last Name exactly
how it is given on the patient’s
Medicare card.
*1
NM1 Subscriber First Name
Enter the First Name exactly
how it is given on the patient’s
Medicare card.
*1
NM Subscriber Identification
Code Qualifier
NM108 – Identification Code
Qualifier
*1
NM Subscriber Identification
Code
NM109 –Identification Code
*1
DMG Subscriber Birth Date
*1
DTP Service Date
SITUATIONAL
DTP Service Date
SITUATIONAL
Loop 2110C
EQ - Service Type Code
SITUATIONAL
Patient Medicare Number
(HIC Number or Rail Road
Benefits Number – RRB)
Patient Medicare Number
(HIC Number or Rail Road
Benefits Number – RRB)
This ID number must match
exactly to what is on the
patient’s Medicare card.
Patient’s Birth Date
Birth date is required for
Beneficiary Identification.
DMG02 – Subscriber Birth
Date
CCYYMMDD
DTP01 – Date/Time
Qualifier
102 – Issue
307 – Eligibility
435 –
Admissions
472 – Service
D8
or
RD8
All codes are acceptable.
The same eligibility data is
required.
CCYYMMDD
or
CCYYMMDD –
CCYYMMDD
Service Date
DTP02 – Date/Time Period
Format Qualifier
SITUATIONAL
DTP Service Date
MI
DTP03 – Service Start Date
CMS will not provide
specific benefits for
corresponding EQ if dates
are sent with this loop. All
benefits will be provided as
of the 2100C DTP request
dates.
Note: Do not send Dependent Loop with a 270 request. Medicare will only return a response for the
Subscriber level information.- 5/16/06
Page 147 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Mega Life and Health Insurance
Search Options
Code
Search Option
*1
Subscriber 1
*2
Dependent 1
Field 1 Search
Subscriber
Last Name
Dependent
Last Name
Field 2 Search
Subscriber
First Name
Dependent
First Name
Field 3 Search
Subscriber DOB
Dependent DOB
Payer Name
Payer Name
Mega Life and Health Insurance
Payer ID^
59221
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
59221
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
FI
Federal Tax ID
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification Code
NM108 – Identification Code
Qualifier
Federal Tax ID
XX
Service Provider NPI
SITUATIONAL
Page 148 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
NM109 – Identification Code
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
REF01 – Identification Code
Qualifier
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
REF02 – Identification Code
Service Provider NPI
TJ
Service Provider Tax ID
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Member ID
REQUIRED
NM1 Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
*1
NM1 Subscriber First Name
*1
DMG Subscriber Birth Date
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
Subscriber Member ID
Subscriber Member ID
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
*1
REF Subscriber
Group Number
REF01 – Reference
Identification Qualifier
6P
Group Number
OPTIONAL
REF Subscriber
Group Number
REF02 – Reference
Identification
OPTIONAL
DTP Service Start Date
DTP01 – Date/Time Qualifier
472
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
Group Number
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
Page 149 of 259
Service Start Date
Required for Subscriber
search.
SITUATIONAL
Loop 2110C
EQ - Service Type Code
Service Start Date
Required for Subscriber
search.
EQ01- Service Type Code
30
Required for Subscriber
search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Value
Definitions and Notes
Specific to ICS
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
REF Dependent
Group Number
REF01 – Reference
Identification Qualifier
6P
Group Number
OPTIONAL
REF Dependent
Group Number
REF02 – Reference
Identification
Loop 2100D
NM Dependent Last Name
Reference
Designator(s)
NM103 – Dependent Last
Name
*2
NM Dependent First Name
NM103 – Dependent First
Name
*2
NM Dependent Birth Date
*2
Group Number
OPTIONAL
DTP Service Start Date
DTP01 – Date/Time Qualifier
472
Required for Dependent
search.
SITUATIONAL
DTP Service Start Date
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
Service Start Date
Required for Dependent
search.
EQ01- Service Type Code
30
Required for Dependent
search.
SITUATIONAL
DTP Service Start Date
SITUATIONAL
Loop 2110D
EQ - Service Type Code
SITUATIONAL
Page 150 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Mega Life (TransAmerica Life)
Search Options
Code
Search Option
*1
Subscriber 1
*2
Dependent 1
Field 1 Search
Subscriber
Last Name
Dependent
Last Name
Field 2 Search
Subscriber
First Name
Dependent
First Name
Field 3 Search
Subscriber DOB
Dependent DOB
Payer Name
Payer Name
Mega Life (TransAmerica Life)
Payer ID^
TLINS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
00208
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
FI
Federal Tax ID
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
NM109 – Identification Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification Code
Qualifier
Federal Tax ID
XX
Service Provider NPI
SITUATIONAL
Page 151 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
NM109 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider NPI
TJ
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
REF02 – Identification Code
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Member ID
NM108 – Identification Code
Qualifier
MI
Subscriber Member ID
REQUIRED
NM1 Subscriber Member ID
NM109 – Identification Code
Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
NM103 – Subscriber Last
Name
*1
NM1 Subscriber First Name
*1
DMG Subscriber Birth Date
NM104 – Subscriber First
Name
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
REF Subscriber
Group Number
REF01 – Reference
Identification Qualifier
6P
Group Number
OPTIONAL
REF Subscriber
Group Number
REF02 – Reference
Identification
*1
Group Number
OPTIONAL
DTP Service Start Date
DTP01 – Date/Time Qualifier
472
Required for Subscriber
search.
SITUATIONAL
DTP Service Start Date
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
SITUATIONAL
DTP Service Start Date
Required for Subscriber
search.
SITUATIONAL
Loop 2110C
EQ - Service Type Code
SITUATIONAL
Page 152 of 259
Service Start Date
EQ01- Service Type Code
30
Required for Subscriber
search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100D
NM Dependent Last Name
NM103 – Dependent Last
Name
*2
NM Dependent First Name
NM103 – Dependent First
Name
*2
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
REF Dependent
Group Number
REF01 – Reference
Identification Qualifier
6P
Group Number
OPTIONAL
REF Dependent
Group Number
REF02 – Reference
Identification
NM Dependent Birth Date
*2
Group Number
OPTIONAL
DTP Service Start Date
DTP01 – Date/Time Qualifier
472
Required for Dependent
search.
SITUATIONAL
DTP Service Start Date
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
SITUATIONAL
DTP Service Start Date
Service Start Date
Required for Dependent
search.
SITUATIONAL
Loop 2110D
EQ - Service Type Code
SITUATIONAL
Page 153 of 259
EQ01- Service Type Code
30
Required for Dependent
search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Missouri Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Search
Option
Code
*1
*2
Field 1
Search
Subscriber
Subscriber Last Name
Subscriber
Dependent Last Name
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Subscriber
First Name
Subscriber
First Name
Subscriber
DOB
Subscriber
Member ID
Subscriber
Member ID
Dependent
Last Name
Subscriber
Gender
Dependent
First Name
Dependent
DOB
Dependent
Gender
Payer Name
Payer Name
Missouri Blue Cross Blue Shield
Payer ID ^
MOBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
REQUIRED
NM1 Information Source Name
NM109 - Identification Code
MOBLS
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
NM1 Information Receiver
Provider ID
REQUIRED
REF Information Receiver
Service Provider ID
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification Code
Qualifier
SV
XX
Provider ID
NPI
Q4
Service Provider ID
NM109 – Identification Code
REF01 – Identification Code
Qualifier
SITUATIONAL
Page 154 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Service Provider ID
REF02 – Identification Code
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
NM108 – Identification Code
Qualifier
MI
Subscriber Member ID
REQUIRED
NM Subscriber Member ID
NM109 – Identification Code
Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
*1
NM103 – Subscriber Last
Name
Required for Subscriber
Search.
NM104 – Subscriber First
Name
Required for Subscriber
Search.
SITUATIONAL
NM1 Subscriber First Name
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
DMG01 – Subscriber Birth
Date
D8
Required for Subscriber
Search.
DMG02 – Subscriber Birth
Date
CCYYMMDD
Required for Subscriber
Search.
DTP01 – Date/Time Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
Loop 2110C
DTP Eligibility Date
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
EQ - Service Type Code
EQ01- Service Type Code
30
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Eligibility
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Page 155 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D
NM1 Dependent Last Name
*2
NM103 – Dependent Last
Name
Required for Dependent
Search.
NM104 – Dependent First
Name
Required for Dependent
Search.
SITUATIONAL
NM1 Dependent First Name
*2
SITUATIONAL
DMG Dependent Birth Date
DMG01 – Dependent Birth
Date
D8
DMG02 – Dependent Birth
Date
CCYYMMDD
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
Loop 2110D
DTP Eligibility Date
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
EQ01- Service Type Code
30
*2
SITUATIONAL
DMG Dependent Birth Date
*2
SITUATIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Date expressed as
CCYYMMDD.
Required for Dependent
Search.
Required for Dependent
Search.
Eligibility
Eligibility
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
EQ - Service Type Code
SITUATIONAL
Page 156 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Missouri Medicaid
Search Options
Code
*1
*2
*3
*4
Search Option
Field 1 Search
Field 2 Search
Field 3 Search
Subscriber 1 Subscriber Member ID
Subscriber 2
Subscriber SSN
Subscriber DOB
Subscriber 3
Subscriber Last Name Subscriber First Name
Subscriber DOB
Subscriber 4 Subscriber Member ID
Dependent DOB
Subscriber First Name
Payer Name
Payer Name
Missouri Medicaid
Payer ID
MOMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM1 Information Source Name
REQUIRED
NM109 - Identification Code
MOMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider ID
NM109 – Identification Code
NM108 – Identification Code
Qualifier
Service Provider ID
XX
Service Provider NPI
SITUATIONAL
Page 157 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
NM109 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider NPI
Q4
REF02 – Identification Code
Service Provider ID
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*3
NM1 Subscriber First Name
*3
NM Subscriber Member ID
*1, *4
NM Subscriber Member ID
*1, *4
REF Subscriber SSN
*2
REF Subscriber SSN
*2
DMG Subscriber Birth Date
*2
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
REF01 – Reference
Identification Qualifier
Subscriber Member ID
SY
REF02 – Reference
Identification
SITUATIONAL
DTP Service End Date
Social Security Number
Social Security Number
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time Qualifier
472
Service Start Date
Required for Subscriber
search
DTP02 – Date/Time Period
Format Qualifier
RD8
Service Date Range
DTP03 – Service Start Date
CCYYMMDD –
CCYYMMDD
Service Start Date
DTP01 – Date/Time Qualifier
472
Service End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service End Date Range
SITUATIONAL
DTP Service End Date
Subscriber Member ID
Required for Subscriber
search.
Cannot be more than 1 year
prior to current date.
Cannot extend beyond the
current month.
Date span cannot be more
than 31 days.
SITUATIONAL
Page 158 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Service End Date
DTP03 – Date/Time Period
Format Qualifier
RD8
CCYYMMDD CCYYMMDD
SITUATIONAL
Service End Date
Required for Subscriber
search.
Cannot be more than 1 year
prior to current date.
Cannot extend beyond the
current month.
Date span cannot be more
than 31 days.
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
30
REQUIRED
Required for Subscriber
search.
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100D
DMG Dependent Birth Date
*4
INS Individual Relationship
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
DMG02 – Dependent Date of
Birth
CCYYMMDD
For newborn.
INS02 – Individual
Relationship Code
19 = Child
Required for Dependent
search.
DTP01 – Date/Time Qualifier
472
Service Start Date
Required for Dependent
search.
DTP02 – Date/Time Format
Qualifier
RD8
Service Date Range
DTP03 - Service Start Date
CCYYMMDD –
CCYYMMDD
Required for Dependent
search.
Cannot be more than 1 year
prior to current date.
Cannot extend beyond the
current month.
Date span cannot be more
than 31 days.
SITUATIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
DTP01 – Date/Time Qualifier
472
Required for Dependent
search.
DTP02 – Date/Time Format
Qualifier
RD8
Service End Date Range
DTP03 - Service Start Date
CCYYMMDD CCYYMMDD
Service End Date
30
Required for Dependent
search.
OPTIONAL
Loop 2110D
EQ - Service Type Code
SITUATIONAL
Page 159 of 259
Service End Date
EQ01- Service Type Code
Required for Dependent
search.
Cannot be more than 1 year
prior to current date.
Cannot extend beyond the
current month.
Date span cannot be more
than 31 days.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Mutual of Omaha
Search Options
Code
Search
Option
*1
Subscriber
*2
Dependent
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Subscriber
Member ID
Subscriber
Member ID
Subscriber
Group Number
Subscriber
Group Number
Subscriber
Last Name
Subscriber
Last Name
Subscriber
First Name
Subscriber
First Name
Field 5
Search
Field 6
Search
Field 7
Search
Field 8
Search
Subscriber
DOB
Dependent Dependent Dependent Dependent
Relation Last Name First Name
DOB
Payer Name
Payer Name
Mutual of Omaha
Payer ID
71412
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
71412
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider Tax ID
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
FI
Service Provider Tax ID
SITUATIONAL
NM1 Information Receiver
Service Provider Tax ID
NM109 – Identification Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification Code
Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification Code
Service Provider Tax ID
XX
Service Provider NPI
Service Provider NPI
SITUATIONAL
Page 160 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF01 – Identification Code
Qualifier
TJ
REF02 – Identification Code
Service Provider Tax ID
Service Provider Tax ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Subscriber Last
Name
REQUIRED
NM1 Subscriber First Name
REQUIRED
NM1 Subscriber Member ID
NM104 – Subscriber First
Name
NM108 – Identification Code
Qualifier
REQUIRED
NM1 Subscriber Member ID
NM109 – Identification Code
REQUIRED
REF Subscriber
Group Number
REF01 – Reference
Identification Qualifier
*1
REF Subscriber
Group Number
*1
DMG Subscriber Birth Date
MI
Subscriber Member ID
Subscriber Member ID
6P
REF02 – Reference
Identification
Subscriber Group Number
Subscriber Group Number
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time Qualifier
472
DTP02 – Date/Time Period
Format Qualifie
D8
Service Start Date –
Required for Subscriber
search
Service Start Date
DTP03 – Service Start Date
CCYYMMDD
DTP01 – Date/Time Qualifier
472
Service End Date
DTP02 – Date/Time Period
Format Qualifier
D8
Service End Date
DTP03 – Date/Time Period
Format Qualifier
CCYYMMDD
Service End Date
EQ01- Service Type Code
30
Required for Subscriber
search.
*1
DTP Service Start Date
*1
DTP Service Start Date
*1
DTP Service Start Date
*1
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110C
EQ - Service Type Code
*1
Page 161 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
NM103 – Dependent Last
Name
Dependent Last Name
NM104 – Dependent First
Name
Dependent First Name
NM105 – Dependent Middle
Initial
Dependent Middle Initial
*2
NM1 Dependent First Name
*2
NM Dependent Middle Initial
OPTIONAL
DMG Dependent Birth Date
DMG02 – Dependent Date of
Birth
CCYYMMDD
INS02 – Individual
Relationship Code
01 = Spouse
19 = Child
34 = Other
Adult
472
*2
INS Individual Relationship
*2
DTP Service Start Date
DTP01 – Date/Time Qualifier
*2
Required for Dependent
search.
Service Start Date
Required for Dependent
search.
Service Start Date
DTP02 – Date/Time Format
Qualifier
D8
DTP Service Start Date
DTP03 - Service Start Date
CCYYMMDD
*2
DTP Service End Date
Required for Dependent
search.
DTP01 – Date/Time Qualifier
472
Service End Date
DTP02 – Date/Time Format
Qualifier
D8
Service End Date
DTP03 - Service Start Date
CCYYMMDD
Service End Date
EQ01- Service Type Code
30
DTP Service Start Date
*2
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110D
EQ - Service Type Code
*2
Page 162 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
National Association of Letter Carriers (NALC)
Search Options
Code
*1
*2
Search Option
Subscriber 1
Dependent 2
Field 1 Search
Subscriber Last Name
Dependent Last Name
Field 2 Search
Subscriber First Name
Dependent First Name
Field 3 Search
Subscriber DOB
Dependent DOB
Payer Name
Payer Name
National Association of Letter Carriers (NALC)
Payer ID^
53011
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
53011
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
FI
Federal Tax ID Number
NM109 – Identification Code
NM108 – Identification Code
Qualifier
NM109 – Identification Code
Federal Tax ID Number
XX
Service Provider NPI
Service Provider NPI
SITUATIONAL
Page 163 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF01 – Identification Code
Qualifier
TJ
REF02 – Identification Code
Service Provider Tax ID
Service Provider Tax ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
REQUIRED
NM Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
*1
NM1 Subscriber First Name
*1
DMG Subscriber Birth Date
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
Subscriber Member ID
Subscriber Member ID
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
*1
REF Subscriber
Group Number
REF01 – Reference
Identification Qualifier
6P
Subscriber Group Number
OPTIONAL
REF Subscriber
Group Number
REF02 – Reference
Identification
OPTIONAL
DTP Service Start Date
DTP01 – Date/Time Qualifier
Subscriber Group Number
472
Service Start Date
Required for Subscriber search.
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
Service Start Date
DTP03 – Service Start Date
CCYYMMDD
Service Start Date
Required for Subscriber search.
SITUATIONAL
Loop 2110C
EQ - Service Type Code
SITUATIONAL
EQ01- Service Type Code
30
Required for Subscriber
search.
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
Page 164 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Dependent Last Name
NM103 - Dependent Last
Name
*2
NM1 Dependent First Name
NM104 - Dependent First
Name
*2
DMG Dependent Birth Date
DMG02 – Dependent Date of
Birth
CCYYMMDD
Dependent Birth Date
REF01 – Reference
Identification Qualifier
6P
Subscriber Group Number
*2
REF Subscriber
Group Number
OPTIONAL
REF Subscriber
Group Number
REF02 – Reference
Identification
Subscriber Group Number
OPTIONAL
DTP Service Start Date
DTP01 – Date/Time Qualifier
472
Service Start Date
Required for Dependent search.
SITUATIONAL
DTP Service Start Date
DTP02 – Date/Time Format
Qualifier
D8
CCMMYYDD
DTP03 - Service Start Date
CCYYMMDD
SITUATIONAL
DTP Service Start Date
Loop 2110D
EQ - Service Type Code
REQUIRED
Page 165 of 259
Service Start Date
Required for Dependent search.
SITUATIONAL
EQ01- Service Type Code
30
Required for Dependent
search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
New Hampshire Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Search
Option
Code
*1
*2
Field 1
Search
Subscriber
Subscriber Last Name
Subscriber
Dependent Last Name
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Subscriber
First Name
Subscriber
First Name
Subscriber
DOB
Subscriber
Member ID
Subscriber
Member ID
Dependent
Last Name
Subscriber
Gender
Dependent
First Name
Dependent
DOB
Dependent
Gender
Payer Name
Payer Name
New Hampshire Blue Cross Blue Shield
Payer ID ^
NHBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
NHBLS
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification Code
Qualifier
SV
XX
Provider ID
NPI
Q4
If NM108 is equal to SV,
segment should be Provider ID.
If NM108 is equal to XX,
segment should be NPI.
Service Provider ID
REQUIRED
NM1 Information Receiver
Provider ID
REQUIRED
REF Information Receiver
Service Provider ID
NM109 – Identification Code
REF01 – Identification Code
Qualifier
SITUATIONAL
Page 166 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Service Provider ID
REF02 – Identification Code
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
REQUIRED
NM Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
*1
SITUATIONAL
NM1 Subscriber First Name
*1
SITUATIONAL
DMG Subscriber Birth Date
NM108 – Identification Code
Qualifier
MI
Subscriber Member ID
NM109 – Identification Code
Subscriber Member ID
NM103 – Subscriber Last
Name
Required for Subscriber Search.
NM104 – Subscriber First
Name
Required for Subscriber Search.
DMG01 – Subscriber Birth
Date
D8
DMG02 – Subscriber Birth
Date
CCYYMMDD
Required for Subscriber Search.
Required for Subscriber Search.
DMG03 – Subscriber Gender
Code
M
F
Male
Female
DTP01 – Date/Time Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
Loop 2110C
DTP Eligibility Date
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
EQ - Service Type Code
EQ01- Service Type Code
30
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DMG Subscriber Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Date expressed as
CCYYMMDD.
Eligibility
SITUATIONAL
Page 167 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
*2
SITUATIONAL
NM1 Dependent First Name
*2
SITUATIONAL
DMG Dependent Birth Date
*2
SITUATIONAL
DMG Dependent Birth Date
NM103 – Dependent Last
Name
Required for Dependent Search.
NM104 – Dependent First
Name
Required for Dependent Search.
DMG01 – Dependent Birth
Date
D8
Date expressed as
CCYYMMDD.
Required for Dependent Search.
DMG02 – Dependent Birth
Date
CCYYMMDD
Required for Dependent Search.
DMG02 – Dependent Gender
Code
M
F
Male
Female
DTP01 – Date/Time Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
Loop 2110D
DTP Eligibility Date
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
EQ - Service Type Code
EQ01- Service Type Code
30
*2
SITUATIONAL
DMG Dependent Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Eligibility
SITUATIONAL
Page 168 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
New Jersey Blue Cross Blue Shield (Horizon)
Search Options
Code
*1
*2
Search Option
Subscriber 1
Subscriber 2
Field 1 Search
Subscriber Last Name
Dependent Last Name
Field 2 Search
Subscriber First Name
Dependent First Name
Field 3 Search
Subscriber DOB
Dependent DOB
Payer Name
Payer Name
New Jersey Blue Cross Blue Shield (Horizons)
Payer ID
22099
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
22099
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM101 - Entity Identifier Code
1P
Provider
NM102 - Entity Type Qualifier
2
Non-Person Entity
NM101 - Entity Identifier Code
1P
Provider
NM108 - Identification Code
Qualifier
FI
Federal Tax ID Number
NM109 – Identification Code
NM108 – Identification Code
Qualifier
Federal Tax ID Number
XX
Service Provider NPI
SITUATIONAL
Page 169 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
NM109 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider NPI
TJ
REF02 – Identification Code
Service Provider Tax ID
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*1
NM1 Subscriber First Name
*1
DMG Subscriber Birth Date
*1
DTP Service Start Date
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time Qualifier
472
Service Start Date
Required for Subscriber search.
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
Service Start Date
DTP03 – Service Start Date
CCYYMMDD
Service Start Date
Required for Subscriber search.
SITUATIONAL
NM Subscriber Member ID
NM108 – Identification Code
Qualifier
REQUIRED
NM Subscriber Member ID
NM109 – Identification Code
REQUIRED
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
SITUATIONAL
Page 170 of 259
MI
Subscriber Member ID
Reciprocity ID:
Position 1 = N, Positions 2-10 =
numeric.
SSN ID:
Positions 1-9 = numeric; or
Positions 1-9 = numeric,
Positions 10 = space,
Position 11 = alpha, and
Position 12 = numeric
10-Digit ID:
Positions 1-10 = numeric
Subscriber Member ID
30
Required for Subscriber
search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM103 -Dependent Last Name
NM103 - Dependent Last Name
NM1 Dependent First Name
NM104 - Dependent First Name
*2
DMG Dependent Birth Date
DMG02 – Dependent Date of
Birth
CCYYMMDD
Dependent Birth Date
DTP01 – Date/Time Qualifier
472
Service Start Date
*2
DTP Service Start Date
Required for Dependent search.
SITUATIONAL
DTP Service Start Date
DTP02 – Date/Time Format
Qualifier
D8
DTP03 - Service Start Date
CCYYMMDD
SITUATIONAL
DTP Service Start Date
SITUATIONAL
Service Start Date
Required for Dependent search.
Loop 2110D
EQ - Service Type Code
EQ01- Service Type Code
30
Required for Dependent
search.
REQUIRED
Page 171 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
New Jersey Medicaid
Search Options
Code
*1
*2
*3
*4
*5
Search Option
Subscriber 1
Subscriber 2
Subscriber 2
Subscriber 3 @
Subscriber 4 @
Field 1 Search
Subscriber ID Card Number
Subscriber Member ID
Subscriber SSN
Subscriber Last Name
Subscriber Last Name
Field 2 Search
Field 3 Search
Subscriber DOB
Subscriber First Name
Subscriber First Name
Subscriber SSN
Subscriber DOB
@Available to Hospital Providers only.
Payer Name
Payer Name
New Jersey Medicaid
Payer ID
NJMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
NJMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider Number
NM109 – Identification Code
Service Provider Number
SITUATIONAL
Page 172 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
NM108 – Identification Code
Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification Code
SITUATIONAL
REF Information Receiver
Service Provider ID
REF01 – Identification Code
Qualifier
XX
Service Provider NPI
Service Provider NPI
Q4
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Subscriber Last Name
*4, *5
M1 Subscriber First Name
NM104 – Subscriber First Name
*4, *5
NM Subscriber Member ID
*2
NM Subscriber Member ID
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
Subscriber Member ID
Subscriber Member ID
*2
REF Subscriber ID Card
Number
REF01 – Reference Identification
Qualifier
HJ
Identity Card Number
Subscriber ID Card Number
*2, *3
REF Subscriber SSN
REF02 – Reference
Identification
Subscriber ID Card Number
*2, *3
REF Subscriber SSN
REF01 – Reference Identification
Qualifier
SY
Subscriber SSN
*2, *3
REF Subscriber SSN
REF02 – Reference
Identification
Subscriber SSN
*2, *3
DMG Subscriber Birth Date
DMG02 – Subscriber Birth Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time Qualifier
472
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service Start Date Range
DTP03 – Service Start Date
CCYYMMDD
CCYYMMDD
Service Start Date
*2, *4
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
Page 173 of 259
Cannot be more than 1 year
prior to current date.
Future dates not to span
calendar months.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Service End Date
REQUIRED
DTP Service End Date
REQUIRED
DTP Service End Date
DTP01 – Date/Time Qualifier
472
Service End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service End Date Range
DTP03 – Service End Date
CCYYMMDD
CCYYMMDD
Service End Date
Date span cannot be more
than 90 days.
EQ01- Service Type Code
30
REQUIRED
Loop 2110C
EQ - Service Type Code
REQUIRED
Added search option for “Subscriber ID Card Number” 6/19/06^
Page 174 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
New Mexico Medicaid
Search Options
Code
Search Option
*1
Subscriber 1
*2
Subscriber 2
*3
*4
Subscriber 3
Subscriber 4
*5
Subscriber 5
Field 1 Search
Subscriber
Member ID
Subscriber ID
Card Number @
Subscriber SSN
Subscriber SSN
Subscriber
Last Name
Field 2 Search
Field 3 Search
Subscriber
Last Name
Subscriber DOB
Subscriber
First Name
Subscriber
First Name
Subscriber DOB
Field 4
Search
Subscriber
Gender
Payer Name
Payer Name
New Mexico Medicaid
Payer ID
NMMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
NMMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider ID
NM109 – Identification Code
Service Provider ID
SITUATIONAL
Page 175 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
NM108 – Identification Code
Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification Code
SITUATIONAL
REF Information Receiver
Service Provider ID
REF01 – Identification Code
Qualifier
XX
Service Provider NPI
Service Provider NPI
Q4
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Subscriber Last Name
*3, *5
NM1 Subscriber First Name
NM104 – Subscriber First Name
*3, *5
NM Subscriber Member ID
*1
NM Subscriber Member ID
NM108 – Identification Code
Qualifier
NM109 – Identification Code
*1
REF Subscriber
ID Card Number
REF01 – Reference
Identification Qualifier
*2
REF Subscriber
ID Card Number
REF02 – Reference
Identification
*2
REF Subscriber SSN
*3, *4
REF Subscriber SSN
*3, *4
DMG Subscriber Birth Date
MI
REF01 – Reference
Identification Qualifier
Subscriber Member ID
HJ
Use this code when the Identity
Card Number is different than the
Member Identification Number.
SY
REF02 – Reference
Identification
CCYYMMDD
DMG03 – Gender Code
F = Female
M = Male
*5
DTP Service Start Date
DTP01 – Date/Time Qualifier
472
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
Subscriber Birth Date
Service Start Date
Service Start Date
Cannot be more than 1 year prior
to current date. No future dates.
REQUIRED
Loop 2110C
EQ - Service Type Code
Social Security Number
Social Security Number
DMG02 – Subscriber Birth Date
REQUIRED
DTP Service Start Date
Subscriber ID Card Number
Subscriber ID Card Number
*4, *5
DMG Subscriber Gender
REQUIRED
DTP Service Start Date
Subscriber Member ID
EQ01- Service Type Code
30
REQUIRED
Page 176 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
New York Blue Cross Blue Shield (Empire)
Search Options
Code
*1
*2
Search
Option
Subscriber 1
Dependent 1
Field 1 Search
Subscriber Last Name
Dependent Last Name
Field 2 Search
Subscriber First Name
Dependent First Name
Field 3 Search
Subscriber DOB
Dependent DOB
Payer Name
Payer Name
New York Blue Cross Blue Shield (Empire)
Payer ID
NYBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
PI
VALUE
Empire Health Choice
Assurance Inc.
Payer Identification
NYBLS
Carrier ID
NM103 – Organization
Name
NM108 - Identification Code
Qualifier
NM109 - Identification Code
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
Page 177 of 259
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider Number
NM109 – Identification
Code
NM108 – Identification
Code Qualifier
Service Provider Number
XX
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
NM109 – Identification
Code
REF01 – Identification Code
Qualifier
Service Provider NPI
Q4
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*1
NM1 Subscriber First Name
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
*1
NM Subscriber Member ID @
REQUIRED
NM Subscriber Member ID @
REQUIRED
NM Subscriber Member ID @
REQUIRED
NM Subscriber Member ID @
REQUIRED
DMG Subscriber Birth Date
NM101 – Entity Identifier
Code
IL
NM102 – Entity Type
Qualifier
NM108 – Identification Code
Qualifier
Subscriber Member ID
Subscriber Member ID
MI
NM109 – Identification
Code
Member Identification
Number
Member Identification
Number See Notes Below
DMG01 – Date/Time Period
Format Qualifier
D8
CCYYMMDD
Subscriber Birth Date
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
307
Eligibility Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Eligibility Start
Date
CCYYMMDD
Eligibility Start Date
DTP01 – Date/Time
Qualifier
307
Eligibility End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Eligibility Date Range
OPTIONAL
DTP Eligibility End Date
DTP03 – Service Start Date
CCYYMMDD –
CCYYMMDD
Eligibility End Date
OPTIONAL
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
*1
DMG Subscriber Birth Date
*1
DTP Eligibility Start Date
OPTIONAL
DTP Eligibility Start Date
OPTIONAL
DTP Eligibility Start Date
OPTIONAL
DTP Eligibility End Date
OPTIONAL
DTP Eligibility End Date
REQUIRED
Page 178 of 259
Required for Subscriber
search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM Dependent Last Name
*2
NM Dependent Last Name
*2
NM Dependent Last Name
*2
NM Dependent First Name
*2
NM Dependent Birth Date
*2
DTP Eligibility Start Date
OPTIONAL
DTP Eligibility Start Date
OPTIONAL
DTP Eligibility Start Date
OPTIONAL
DTP Eligibility End Date
OPTIONAL
DTP Eligibility End Date
OPTIONAL
DTP Eligibility End Date
OPTIONAL
Loop 2110D
EQ - Service Type Code
REQUIRED
NM101 – Entity Identifier
Code
03
Dependent
NM102 – Entity Type
Qualifier
1
Person
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
DTP01 – Date/Time
Qualifier
307
Eligibility Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Eligibility Start
Date
CCYYMMDD
Eligibility Start Date
DTP01 – Date/Time
Qualifier
307
Eligibility End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Eligibility End Date Range
DTP03 – Eligibility End Date
CCYYMMDD –
CCYYMMDD
Eligibility End Date
NM103 – Dependent Last
Name
NM104 – Dependent First
Name
EQ01- Service Type Code
Required for Dependent search.
@Card Swipe.
Member ID requirements:
Member ID must be the assigned Subscriber ID that is on the ID card. Do not enter suffix or the
dependent number.
ID numbers must:
 Be left justified.
 Not contain leading spaces.
 Not contain all alpha characters.
 Not contain embedded spaces or special characters.
 Prefix may be 1-3 positions.
 Subscriber ID number must begin immediately following the alpha prefix.
 ID number must not contain all 1’s, 2’s, 3’s, 4’s, 5’s, 6’s, 7’s, 8’s, 9’s, 0’s,
123456789, 1234567890, or literals such as UNKNOWN, UNK, INDIVIDUAL, SELF, or
NONE.
Page 179 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
New York Medicaid
Search Options
Code
Search
Option
*1
Subscriber 1
*2
Subscriber 2
*3
Subscriber 3
*4
Subscriber 4
Field 2
Field 1 Search
Search
Subscriber Member ID
(8-byte Medicaid
Subscriber ID
Recipient ID)
Card Number
Subscriber Member ID
(13-byte Medicaid
Access Number)
Subscriber Member ID
(19-byte Common
Benefit ID Card Number)
Subscriber
Subscriber SSN
Last Name
Field 3
Search
Field 4
Search
Subscriber
First Name
Field 5
Search
Subscriber Subscriber
DOB
Gender
Payer Name
Payer Name
New York Medicaid
Payer ID
NYMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Payer
ID
REQUIRED
NM1 Information Source Payer
ID
REQUIRED
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
NYMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
NM101 - Entity Identifier
Code
1P
Provider
The default value is 1P.
All other values are accepted.
NM102 – Entity Type
Qualifier
2
Non-Person Entity
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
Page 180 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider ID
NM108 – Identification Code
Qualifier
SITUATIONAL
NM1 Information Receiver
Provider ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information Receiver
Service Provider ID
REF01 – Identification Code
Qualifier
SV
Service Provider Number
Provider Number
XX
Service Provider NPI
Service Provider NPI
Q4
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*4
NM1 Subscriber First Name
*4
NM Subscriber Member ID
*1
NM Subscriber Member ID
*1
NM Subscriber Member ID
*2
NM Subscriber Member ID
*2
NM Subscriber Member ID
*3
NM Subscriber Member ID
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
NM108 – Identification Code
Qualifier
NM109 – Identification
Code
NM108 – Identification Code
Qualifier
NM108 – Identification
Code Qualifier
*1
REF Subscriber
ID Card Number
REF02 – Reference
Identification
Page 181 of 259
MI
Member Access Number
Medicaid Access Number
MI
NM109 – Identification
Code
REF01 – Reference
Identification Qualifier
Member Recipient ID
Medicaid Recipient ID
NM109 – Identification Code
*3
REF Subscriber
ID Card Number
*1
MI
Common Benefit ID Card
Number
Common Benefit ID Card
Number
GH
Subscriber ID Card Number
Subscriber ID Card Number
Required if the 8-byte Medicaid
Recipient ID is valued as the
Member ID. Otherwise, may be
valued at the user’s discretion.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Subscriber SSN
*4
REF Subscriber SSN
*4
DMG Subscriber Birth Date
REF01 – Reference
Identification Qualifier
SY
REF02 – Reference
Identification
Social Security Number
Social Security Number
DMG02 – Subscriber Birth
Date
CCYYMMDD
DMG03 – Gender Code
F = Female
M = Male
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
Subscriber Birth Date
*4
DMG Subscriber Gender
*4
DTP Service Start Date
REQUIRED
DTP Service Start Date
Service Start Date
Cannot be more than 2 years
prior to current date.
No future dates.
REQUIRED
DTP Service Start Date
Service Start Date
Cannot be more than 1 year
prior to current date.
No future dates.
REQUIRED
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
NY Medicaid assumes 30.
SITUATIONAL
Page 182 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Nevada Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Search
Option
Code
*1
*2
Field 1
Search
Subscriber
Subscriber Last Name
Subscriber
Dependent Last Name
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Subscriber
First Name
Subscriber
First Name
Subscriber
DOB
Subscriber
Member ID
Subscriber
Member ID
Dependent
Last Name
Subscriber
Gender
Dependent
First Name
Dependent
DOB
Dependent
Gender
Payer Name
Payer Name
Nevada Blue Cross Blue Shield
Payer ID ^
NVBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier
Code
NM102 – Entity Type
Qualifier
NM108 - Identification Code
Qualifier
PR
Payer
2
Non-Person Entity
PI
Payer Identification
NM109 - Identification Code
NVBLS
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
NM1 Information Receiver
Provider ID
REQUIRED
REF Information Receiver
Service Provider ID
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification Code
Qualifier
SV
XX
Provider ID
NPI
NM109 – Identification
Code
REF01 – Identification Code
Qualifier
If NM108 is equal to SV,
segment should be Provider ID.
Q4
If NM108 is equal to XX,
segment should be NPI.
Service Provider ID
SITUATIONAL
Page 183 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Service Provider ID
REF02 – Identification Code
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
REQUIRED
NM Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
*1
SITUATIONAL
NM1 Subscriber First Name
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DTP Eligibility Date
NM108 – Identification Code
Qualifier
MI
Subscriber Member ID
NM109 – Identification
Code
Subscriber Member ID
NM103 – Subscriber Last
Name
Required for Subscriber Search.
NM104 – Subscriber First
Name
Required for Subscriber Search.
DMG01 – Subscriber Birth
Date
D8
Required for Subscriber Search.
DMG02 – Subscriber Birth
Date
CCYYMMDD
Required for Subscriber Search.
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
EQ - Service Type Code
EQ01- Service Type Code
30
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110C
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Eligibility
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
Page 184 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Dependent Last Name
*2
SITUATIONAL
NM1 Dependent First Name
*2
SITUATIONAL
DMG Dependent Birth Date
NM103 – Dependent Last
Name
Required for Dependent Search.
NM104 – Dependent First
Name
Required for Dependent Search.
DMG01 – Dependent Birth
Date
D8
Required for Dependent Search.
DMG02 – Dependent Birth
Date
CCYYMMDD
Required for Dependent Search.
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
EQ - Service Type Code
EQ01- Service Type Code
30
*2
SITUATIONAL
DMG Dependent Birth Date
*2
SITUATIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110D
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Eligibility
SITUATIONAL
Page 185 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Nevada Medicaid
Search Options
Code
*1
*2
*3
*4
*5
Search Option
Subscriber
Subscriber
Subscriber
Subscriber
Subscriber
Field 1 Search
Member ID
Card Number
SSN
SSN
Last Name
Field 2 Search
Field 3 Search
Date of Birth
Last Name
First Name
First Name
Date of Birth
Payer Name
Payer Name
Nevada Medicaid
Payer ID ^
NVMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier
Code
NM102 – Entity Type
Qualifier
PR
Payer
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
NVMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
Page 186 of 259
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification Code
Qualifier
XX
NPI Qualifier
NM109 – Identification
Code
NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
REQUIRED
NM Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
*4, *5
SITUATIONAL
NM1 Subscriber First Name
*4, *5
SITUATIONAL
DMG Subscriber Birth Date
NM108 – Identification Code
Qualifier
MI
SY
NM109 – Identification
Code
Subscriber Member ID or SSN
NM103 – Subscriber Last
Name
Subscriber Last Name
NM104 – Subscriber First
Name
Subscriber First Name
Required for Subscriber
Searches 4 and 5.
DMG01 – Subscriber Birth
Date
D8
DMG02 – Subscriber Birth
Date
CCYYMMDD
*3, *5
SITUATIONAL
REF Card Control Number
REF01
HJ
Required for Subscriber
Searches 4 and 5.
Date qualifier
Required for Subscriber
Searches 3 and 5.
*3, *5
SITUATIONAL
DMG Subscriber Birth Date
Subscriber Member ID or
SSN Qualifier
Date of Birth
Required for Subscriber
Searches 3 and 5.
Card Control Number Qualifier
Required for Subscriber Search
2.
Card Control Number
*2
SITUATIONAL
REF Card Control Number
*2
SITUATIONAL
REF02
DTP Eligibility Date
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
OPTIONAL
EQ - Service Type Code
CCYYMMDDCCYYMMDD
EQ01- Service Type Code
30
Required for Subscriber Search
2.
Eligibility
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110C
DTP Eligibility Date
Eligibility
OPTIONAL
DTP Eligibility Date
SITUATIONAL
Page 187 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
*2
NM103 – Dependent Last
Name
Required for Dependent Search.
NM104 – Dependent First
Name
Required for Dependent Search.
SITUATIONAL
NM1 Dependent First Name
*2
SITUATIONAL
DMG Dependent Birth Date
DMG01 – Dependent Birth
Date
D8
DMG02 – Dependent Birth
Date
CCYYMMDD
Required for Dependent Search.
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
DTP01 – Date/Time
Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
EQ01- Service Type Code
30
Date expressed as
CCYYMMDD.
*2
SITUATIONAL
DMG Dependent Birth Date
Required for Dependent Search.
*2
SITUATIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110D
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Eligibility
OPTIONAL
EQ - Service Type Code
SITUATIONAL
Page 188 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Nippon Life (Principal Financial Group)
Search Options
Code
*1
*2
Search Option
Subscriber 1
Dependent 1
Field 1 Search
Subscriber Member ID
Subscriber Member ID
Field 2 Search
Subscriber DOB
Subscriber DOB
Field 3 Search
Dependent DOB
Payer Name
Payer Name
Nippon Life (Principal Financial Group)
Payer ID^
81264
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Payer
ID
REQUIRED
NM1 Information Source Payer
ID
REQUIRED
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
81264
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
Page 189 of 259
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
FI
Federal Tax ID
NM109 – Identification
Code
NM108 – Identification
Code Qualifier
NM109 – Identification
Code
Federal Tax ID
XX
Service Provider NPI
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF01 – Identification Code
Qualifier
TJ
REF02 – Identification Code
Service Provider Tax ID
Service Provider Tax ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
*1, *2
NM Subscriber Member ID
*1, *2
DMG Subscriber Birth Date
*1, *2
NM1 Subscriber Last Name
OPTIONAL
NM1 Subscriber First Name
OPTIONAL
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
NM108 – Identification Code
Qualifier
MI
NM109 – Identification
Code
DMG02 – Subscriber Birth
Date
Subscriber Member ID
Subscriber Member ID
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
CCYYMMDD
DTP03 – Service Start Date
CCYYMMDD
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
Required for Subscriber search.
Service Start Date
Required for Subscriber search.
REQUIRED
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
Required for Subscriber search.
Use 41 for best results for
Dental Benefits.
SITUATTIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM Dependent Birth Date
*2
NM Dependent Last Name
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
NM103 – Dependent Last
Name
OPTIONAL
Page 190 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM Dependent First Name
OPTIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
NM104 – Dependent First
Name
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time Period
Format Qualifier
D8
CCYYMMDD
DTP03 – Service Start Date
CCYYMMDD
Service Start Date
Required for Dependent search.
Service Start Date
Required for Dependent search.
SITUATIONAL
Loop 2110D
EQ - Service Type Code
EQ01- Service Type Code
SITUATIONAL
Required for Dependent search.
Use 41 for best results for
Dental Benefits.
Page 191 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
North Carolina Medicaid
Search Options
Code
*1
*2
*3
*4
Search Option
Subscriber 1
Subscriber 2
Subscriber 3
Subscriber 4
Field 1 Search
Subscriber Member ID
Subscriber SSN
Subscriber Last Name
Subscriber Last Name
Field 2 Search
Field 3 Search
Subscriber DOB
Subscriber First Name
Subscriber First Name
Subscriber DOB
Subscriber SSN
Payer Name
Payer Name
North Carolina Medicaid
Payer ID
NCMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
NCMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
Page 192 of 259
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider Number
NM109 – Identification
Code
NM108 – Identification
Code Qualifier
Service Provider Number
XX
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
NM109 – Identification
Code
REF01 – Identification Code
Qualifier
Service Provider NPI
Q4
REF02 – Identification Code
Service Provider ID
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*3, *4
NM1 Subscriber First Name
*3, *4
NM Subscriber Member ID
*1
NM Subscriber Member ID
*1
REF Subscriber SSN
*2, *4
REF Subscriber SSN
*2, *4
DMG Subscriber Birth Date
*2, *3
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
NM108 – Identification Code
Qualifier
MI
NM109 – Identification
Code
REF01 – Reference
Identification Qualifier
Subscriber Member ID
SY
REF02 – Reference
Identification
Social Security Number
Social Security Number
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
No future dates.
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
Service Star Date
No future dates.
DTP01 – Date/Time
Qualifier
472
Service End Date
No future dates.
DTP02 – Date/Time Period
Format Qualifier
RD8
Service End Date Range
No future dates.
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Service End Date Range
No future dates.
EQ01- Service Type Code
30
OPTIONAL
Loop 2110C
EQ - Service Type Code
Subscriber Member ID
REQUIRED
Page 193 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Ohio Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Search
Option
Code
*1
*2
Field 1
Search
Subscriber
Subscriber Last Name
Subscriber
Dependent Last Name
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Subscriber
First Name
Subscriber
First Name
Subscriber
Birth Date
Subscriber
Member ID
Subscriber
Member ID
Dependent
Last Name
Subscriber
Gender
Dependent
First Name
Dependent
Birth Date
Dependent
Gender
Payer Name
Payer Name
Ohio Blue Cross Blue Shield
Payer ID ^
OHBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
NM101 - Entity Identifier
Code
NM102 – Entity Type
Qualifier
PR
Payer
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
OHBLS
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
NM1 Information Receiver
Provider ID
REQUIRED
REF Information Receiver
Service Provider ID
SITUATIONAL
Page 194 of 259
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification Code
Qualifier
SV
XX
Provider ID
NPI
NM109 – Identification
Code
REF01 – Identification Code
Qualifier
If NM108 is equal to SV,
segment should be Provider ID.
Q4
If NM108 is equal to XX,
segment should be NPI.
Service Provider ID
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Service Provider ID
REF02 – Identification Code
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
REQUIRED
NM Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
*1
SITUATIONAL
NM1 Subscriber First Name
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DTP Eligibility Date
NM108 – Identification Code
Qualifier
MI
Subscriber Member ID
NM109 – Identification
Code
Subscriber Member ID
NM103 – Subscriber Last
Name
Required for Subscriber Search.
NM104 – Subscriber First
Name
Required for Subscriber Search.
DMG01 – Subscriber Birth
Date
D8
DMG02 – Subscriber Birth
Date
CCYYMMDD
Required for Subscriber Search.
Required for Subscriber Search.
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
EQ01- Service Type Code
30
Date expressed as
CCYYMMDD.
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110C
EQ - Service Type Code
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
*2
SITUATIONAL
NM1 Dependent First Name
*2
SITUATIONAL
Page 195 of 259
NM103 – Dependent Last
Name
Required for Dependent Search.
NM104 – Dependent First
Name
Required for Dependent Search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DMG Dependent Birth Date
DMG01 – Dependent Birth
Date
D8
Required for Dependent Search.
*2
SITUATIONAL
DMG Dependent Birth Date
*2
SITUATIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
DMG02 – Dependent Birth
Date
CCYYMMDD
Required for Dependent Search.
DTP01 – Date/Time
Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
EQ01- Service Type Code
30
OPTIONAL
Loop 2110D
EQ - Service Type Code
Date expressed as
CCYYMMDD.
SITUATIONAL
Page 196 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Ohio Medicaid
Search Options
Code
*1
*2
*3
*4
Search Option
Subscriber 1
Subscriber 2
Subscriber 3
Subscriber 4
Field 1 Search
Subscriber Member ID
Subscriber SSN
Subscriber SSN
Subscriber Last Name
Field 2 Search
Field 3 Search
Subscriber Last Name Subscriber First Name
Subscriber DOB
Subscriber First Name
Subscriber DOB
Payer Name
Payer Name
Ohio Medicaid
Payer ID
OHMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
OHMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
NM1 Information Receiver
Service Provider NPI
NOT USED
Page 197 of 259
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider Number
NM109 – Identification
Code
NM108 – Identification
Code Qualifier
Service Provider Number
XX
NOTE: Ohio Medicaid requires
the use of the Provider Legacy
ID in the NM109.
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
Service Provider NPI
NOTE: Ohio Medicaid does not
accept the Provider NPI at this
time.
NOT USED
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*2, *4
NM1 Subscriber First Name
*2, *4
NM Subscriber Middle Initial
SITUATIONAL
NM Subscriber Member ID
*1
NM Subscriber Member ID
*1
REF Subscriber SSN
*2, *3
REF Subscriber SSN
*2, *3
DMG Subscriber Birth Date
*3, *4
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service End Date
REQUIRED
DTP Service End Date
REQUIRED
DTP Service End Date
REQUIRED
Loop 2110C
EQ - Service Type Code
REQUIRED
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
NM105 – Subscriber Middle
Initial
NM108 – Identification Code
Qualifier
Required for Name search
and if known.
MI
NM109 – Identification
Code
REF01 – Reference
Identification Qualifier
Subscriber Member ID
Subscriber Member ID
SY
REF02 – Reference
Identification
Social Security Number
Social Security Number
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Service Start Date
DTP01 – Date/Time
Qualifier
472
Service End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service End Date Range
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Service End Date Range
EQ01- Service Type Code
Cannot be more than 1 year prior
to current date. No future dates.
Date Span cannot be more than
30 days.
30
Change to “Service Start Date” from D8 to RD8. 4/17/06^
Change to “Service End Date” from Optional to Required on 4/17/06.^
Page 198 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Oklahoma Medicaid
Search Options
Code
*1
*2
*3
Search Option
Subscriber 1
Subscriber 2
Subscriber 3
Field 1 Search
Subscriber Member ID
Subscriber SSN
Subscriber Last Name
Field 2 Search
Field 3 Search
Subscriber DOB
Subscriber First Name
Subscriber DOB
Payer Name
Payer Name
Oklahoma Medicaid
Payer ID ^
OKMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier
Code
NM102 – Entity Type
Qualifier
PR
Payer
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
OKMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Provider ID
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification Code
Qualifier
SV
Service Provider ID
Either NPI or Provider ID
required.
NM109 – Identification
Code
Service Provider ID
Use the 10-digit provider number
assigned by OHCA:
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM109 – Identification
Code
Page 199 of 259
XX
(9-digit provider number plus the
1-digit location code).
Service Provider NPI
Either NPI or Provider ID
required.
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
3*
NM1 Subscriber First Name
3*
NM1 Subscriber Member ID
1*
NM1 Subscriber Member ID
1*
DMG Subscriber Birth Date
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
NM108 – Identification Code
Qualifier
MI
NM109 – Identification
Code
Subscriber Member ID
DMG02 – Subscriber Birth
Date
CCYYMMDD
2*, 3*
REF – Subscriber Social
Security Number
REF01 – Subscriber Social
Security Number Qualifier
SY
2*
REF – Subscriber Social
Security Number
REF02 – Subscriber Social
Security Number
2*
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
REQUIRED
Page 200 of 259
30
Required for Subscriber
search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Oxford Health Plans
Search Options
Code
Search
Option
*1
Subscriber
*2
Subscriber
*3
Subscriber
*4
Subscriber
Field 1
Search
Subscriber
Member ID
Subscriber
SSN
Subscriber
Last Name
Subscriber
Member ID
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Subscriber
First Name
Subscriber
First Name
Subscriber
Last Name
Subscriber
DOB
Subscriber
First Name
Subscriber
DOB
Service Start
Date
Payer Name
Payer Name
Oxford Health Plans
Payer ID
06111
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier
Code
NM102 – Entity Type
Qualifier
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PR
Payer
2
Non-Person Entity
PI
Payer Identification
06111
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider Tax ID
SITUATIONAL
NM1 Information Receiver
Service Provider Tax ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
Page 201 of 259
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification
Code Qualifier
FI
Service Provider Tax ID
NM109 – Identification
Code
NM108 – Identification
Code Qualifier
Service Provider Tax ID
XX
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
REF01 – Identification Code
Qualifier
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
Service Provider NPI
TJ
REF02 – Identification Code
Service Provider Tax ID
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
REQUIRED
NM1 Subscriber First Name
REQUIRED
NM1 Subscriber Member ID
REQUIRED
NM1 Subscriber Member ID
REQUIRED
REF Subscriber
Group Number
OPTIONAL
REF Subscriber
Group Number
OPTIONAL
DMG Subscriber Birth Date
REQUIRED
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110C
Page 202 of 259
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
NM108 – Identification Code
Qualifier
MI
NM109 – Identification
Code
REF01 – Reference
Identification Qualifier
Subscriber Member ID
Subscriber Member ID
6P
REF02 – Reference
Identification
Subscriber Group Number
Subscriber Group Number
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
DTP01 – Date/Time
Qualifier
472
Service End Date
DTP02 – Date/Time Period
Format Qualifier
D8
Service End Date
DTP03 – Date/Time Period
Format Qualifier
CCYYMMDD
Service End Date
Required for Subscriber search
Service Start Date
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
EQ - Service Type Code
EQ01- Service Type Code
30
Required for Subscriber search.
OPTIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
NM103 – Dependent Last
Name
Dependent Last Name
Required if Patient is NOT the
Subscriber.
Dependent First Name
SITUATIONAL
NM1 Dependent First Name
NM104 – Dependent First
Name
Required if Patient is NOT the
Subscriber.
Dependent Middle Initial
SITUATIONAL
NM Dependent Middle Initial
NM105 – Dependent Middle
Initial
OPTIONAL
DMG Dependent Birth Date
DMG02 – Dependent Date
of Birth
CCYYMMDD
Required if Patient is NOT
the Subscriber.
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time Format
Qualifier
D8
Service Start Date
Required if Patient is NOT
the Subscriber.
Service Start Date
DTP03 - Service Start Date
CCYYMMDD
Required if Patient is NOT
the Subscriber.
DTP01 – Date/Time
Qualifier
472
Service End Date
DTP02 – Date/Time Format
Qualifier
D8
Service End Date
DTP03 - Service Start Date
CCYYMMDD
Service End Date
EQ01- Service Type Code
30
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110D
EQ - Service Type Code
OPTIONAL
Page 203 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Pennsylvania Blue Cross Blue Shield (Highmark)
Enrollment:
The Provider Group NPI must first be enrolled for claim submission with Pennsylvania Blue Cross Blue Shield
(Highmark) before submitting the 270 Request. If the Group NPI has been successfully enrolled for claim
submission, there should not be a problem. If that is not the case, please refer to the ICS website for a copy of the
enrollment form and instructions.
Highmark includes:
- Independence Blue Cross/Highmark Blue Shield Comp Select • Highmark Indemnity -Preferred Provider
Organization PPO • Point of Service POS • Health Maintenance Organization HMO • Comprehensive Major
Medical CMM • Major Medical • Medicare Supplemental • Clarity Vision
Independence Administrators Out-of-Area:
Providers outside of the Independence Blue Cross (IBC) 5 county service area that are not Personal Choice Network
Providers should submit requests with Highmark listed as the Payer/Information Source in the 2100A Loop.
Highmark will use the Member ID alpha prefix to identify the need to coordinate with Independence
Administrators.
The IBC service area includes the following counties: Philadelphia • Bucks • Chester • Delaware • Montgomery.
Search Options
Code
Search Option
*1
Subscriber
*2
Dependent
Field 1 Search
Subscriber
Member ID
Subscriber
Member ID
Field 2 Search
Subscriber
Last Name
Dependent
Last Name
Field 3 Search
Subscriber
First Name
Dependent
First Name
Field 4 Search
Subscriber
DOB
Dependent
DOB
Payer Name
Payer Name
Pennsylvania Blue Cross Blue Shield (Highmark)
Payer ID
PABLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
PABLS
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Page 204 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Organization Name
NM101 - Entity Identifier
code
1P (only)
Provider
NM102 – Entity Type
Qualifier
2
1
Highmark business practices do
not allow for eligibility inquiries
from Third Party Administrators,
Employers or Plan Sponsors.
Non-Person Entity
Person
NM103 – Organization
Name
Organization Name
SITUATIONAL
NM1 Information Receiver Last
Name
NM103 – Last Name
Service Provider Last Name
SITUATIONAL
NM1 Information Receiver
First Name
NM104 – First Name
Service Provider First Name
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
REQUIRED
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
NPI on a Provider Request
NAIC number on a Payer
Request.
REF01 – Identification
Code Qualifier
Service Provider ID
REQUIRED
REF Information Receiver
Service Provider ID
XX
PI
Payer will use the primary
identifier in the NM109.
Service Provider ID
NOT USED
REF Information Receiver
Service Provider ID
NPI on a Provider Request
NAIC number on a Payer
Request.
REF02 – Identification
Code
Payer will use the primary
identifier in the NM109.
NOT USED
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Last Name
Subscriber Last Name
*1
NM1 Subscriber First Name
NM104 – First Name
Subscriber First Name
*1
NM1 Subscriber
Patient Member ID
NM108 – Identification Code
Qualifier
MI
*1, *2
Page 205 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM109 – Identification Code
NM1 Subscriber
Patient Member ID
*1, *2
REF Subscriber SSN
SITUATIONAL
REF Subscriber Patient SSN
Subscriber Member ID
Enter the full Unique Member ID
(Highmark) or Unique Subscriber
ID (IBC) including the alpha
prefix found on the patient's
healthcare ID card.
REF01 – Reference
Identification Qualifier
REF02 – Subscriber SSN
SY
Subscriber Social Security
Number
If known, should be used to help
Highmark identify the patient.
SITUATIONAL
REF01 – Reference
Identification Qualifier
REF Subscriber
Group Number
6P
SITUATIONAL
REF Subscriber
Patient Group Number
SITUATIONAL
REF02 - Subscriber Group
Number
REF Subscriber HIC Number
REF01 – Reference
Identification Qualifier
SITUATIONAL
REF Subscriber Patient HIC
Number
SITUATIONAL
DMG Subscriber Birth Date
*1
DMG Subscriber Birth Date
*1
DMG Subscriber Gender
OPTIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
Loop 2110C
EQ Coverage Level Code
If known, should be used to help
Highmark identify the patient.
F6
REF02 - Subscriber HIC
Number
Subscriber HIC Number
DMG01 – Date/Time Period
Qualifier
D8
If known, should be used to help
Highmark identify the patient.
Date/Time
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DMG03 – Subscriber
Gender Code
M
F
Male
Female
DTP01 – Date/Time
Qualifier
472
435
307
Service
Admission
Eligibility
DTP02 – Date/Time
Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
Service Start Date
Admission Date
Eligibility Date
EQ01 – Benefit Coverage
Level Code
30
Benefit Service Type Code
SITUATIONAL
DTP Service Start Date
Subscriber Group Number
Highmark will provide a
response at the (EQ01) service
type level only.
NOTE: Based on requirements by the Blue Cross Blue Shield Association, all 270 requests containing an EQ01 of
“30” (Health Benefit Plan Coverage), will receive a 271 response that includes EB segments with these EB03 values, if
applicable 30, 48, 50, 52, 98, A7 and A8.
REQUIRED
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Page 206 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
NM103 – Last Name
Dependent Last Name
*2
NM1 Dependent First Name
NM104 – First Name
Dependent First Name
*2
DMG Dependent Birth Date
*2
DMG Dependent Birth Date
*2
DMG Dependent Gender
OPTIONAL
REF Dependent SSN
SITUATIONAL
REF Dependent Patient SSN
DMG01 – Date/Time Period
Qualifier
D8
Date/Time
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
DMG03 – Dependent
Gender Code
M
F
Male
Female
REF01 – Reference
Identification Qualifier
SY
REF02 – Dependent SSN
Patient Social Security Number
If known, should be used to help
Highmark identify the patient.
SITUATIONAL
REF Dependent Group
Number
SITUATIONAL
REF Dependent Patient Group
Number
SITUATIONAL
REF Dependent HIC Number
SITUATIONAL
REF Dependent Patient HIC
Number
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
Loop 2110C
EQ Coverage Level Code
REF01 – Reference
Identification Qualifier
6P
REF02 - Dependent Group
Number
REF01 – Reference
Identification Qualifier
Patient Group Number
If known, should be used to help
Highmark identify the patient.
F6
REF02 - HIC Number
DTP01 – Date/Time
Qualifier
DTP02 – Date/Time
Qualifier
Patient HIC Number
472
435
307
D8
If known, should be used to help
Highmark identify the patient.
Service
Admission
Eligibility
DTP03 – Service Start Date
CCYYMMDD
Service Start Date
Admission Date
Eligibility Date
EQ01 – Benefit Coverage
Level Code
30
Benefit Service Type Code
Highmark will provide a
response at the (EQ01) service
type level only.
NOTE: Based on requirements by the Blue Cross Blue Shield Association, all 270 requests containing an EQ01 of
“30” (Health Benefit Plan Coverage), will receive a 271 response that includes EB segments with these EB03 values, if
applicable 30, 48, 50, 52, 98, A7 and A8.
REQUIRED
Page 207 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
PacifiCare of California (HMO)
Search Options
Code
*1
*2
Search Option
Subscriber 1
Subscriber 2
*3
*4
Dependent 3
Dependent 4
Field 1 Search
Subscriber Member Number
Subscriber SSN
Member Number of the
Patient (or other family
member)
Subscriber SSN
Field 2 Search
Subscriber DOB
Subscriber DOB
Field 3 Search
Subscriber First Name
Patient DOB
Patient DOB
Patient First Name
Patient First Name
Payer Name
Payer Name
PacifiCare of California (HMO)
Payer ID
95959
Loop 2100A – Information Source Name
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
Designator(s)
to ICS
Loop 2100A
NM1 Individual or
Organizational Name
REQUIRED
NM1 Individual or
Organizational Name
REQUIRED
NM1 Individual or
Organizational Name
REQUIRED
NM1 Individual or
Organizational Name
REQUIRED
NM101 - Entity Identifier
Code
PR
Preferred Value:
PR - Payer
NM102 – Entity Type
Qualifier
2
Preferred Value:
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
95959
Carrier ID
Loop 2100B – Information Receiver Name
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
Designator(s)
to ICS
Loop 2100B
NM1 Individual or
Organizational Name
REQUIRED
NM1 Individual or
Organizational Name
REQUIRED
NM1 Individual or
Organizational Name
SITUATIONAL
NM1 Individual or
Organizational Name
SITUATIONAL
Page 208 of 259
NM101 - Entity Identifier
code
1P
Preferred Value:
1P - Provider
NM102 – Entity Type
Qualifier
1, 2
1 - Person
2 - Non-Person Entity
NM103 – Name Last of
Organization Name
Name Last or Organization
Name
NM104 – First Name
Service Provider First Name
Use if NM102 = 1
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Individual or
Organizational Name
SITUATIONAL
NM1 Individual or
Organizational Name
SITUATIONAL
NM108 – Identification Code
Qualifier
FI, XX
NM109 – Identification
Code
FI - Tax ID
XX - NPI
Tax ID or NPI is required.
Loop 2100C – Subscriber Name
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Individual or
Organizational Name
*2
SITUATI0NAL
NM1 Individual or
Organizational Name
*1, *3
SITUATI0NAL
NM1 Individual or
Organizational Name
*1, *3
NM104 – First Name
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
Subscriber Member Number
Preferred Value
MI
Subscriber Member Number
REF Subscriber
Additional Identification
*2, *4
SITUATI0NAL
REF Subscriber
Additional Identification
*2, *4
SITUATI0NAL
DMG Subscriber
Demographic Information
*1, *2
SITUATIONAL
REF01 – Reference
Identification Qualifier
DMG01 – Date/Time Period
Format Qualifier
D8
DMG Subscriber Demographic
Information
*1, *2
DMG02 – Subscriber Birth
Date
CCYYMMDD
DTP01 – Date/Time
Qualifier
102, 307, 435,
472
DTP02 – Date/Time Period
Format Qualifier
D8
- or RD8
Preferred Value:
DTP03 – Service Start Date
CCYYMMDD
- or CCYYMMDD CCYYMMDD
Service Start Date
EQ01 – Service Type Code
Refer to the 270
HIPAA
Implementation
Guide for a list of
values.
Preferred Value:
SITUATIONAL
DTP Subscriber Date
REQUIRED
DTP Subscriber Date
REQUIRED
Loop 2110C
EQ Eligibility or Benefit Inquiry
SITUATIONAL
Page 209 of 259
Preferred Value:
SY - SSN
Only checked if no Member
Number is sent.
Preferred Value:
REF02 – Reference
Identification
REQUIRED
DTP Subscriber Date
SY
Subscriber SSN
Only checked if no Member
Number is sent.
Preferred Value:
If the patient is a subscriber, the
DOB must be supplied to find a
member.
Preferred Value:
307- Eligibility
D8 CCYYMMDD
30 – Generic Request
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Dependent Name
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Individual or
Organizational Name
NM101 – Entity Identifier
Code
03
Dependent
REQUIRED
NM1 Individual or
Organizational Name
NM102 – Entity Type
Qualifier
1
Person
REQUIRED
NM1 Individual or
Organizational Name
*3, *4
NM104 – First Name
Preferred Value:
This field must be populated to
be able to find a dependent.
SITUATIONAL
DMG Dependent
Demographic Information
DMG01 – Date/Time Period
Format Qualifier
D8
DMG02 – Dependent Birth
Date
CCYYMMDD
DTP01 – Date/Time
Qualifier
102, 307, 435,
472
Preferred Value:
DTP02 – Date/Time Period
Format Qualifier
D8
- or RD8
Preferred Value:
DTP03 – Service Start Date
CCYYMMDD
- or CCYYMMDD CCYYMMDD
Service Start Date
EQ01 – Service Type Code
Refer to the 270
HIPAA
Implementation
Guide for a list of
values
Preferred Value:
*3, *4
SITUATIONAL
DMG Dependent
Demographic Information
If the patient is a dependent the
DOB must be supplied to find a
member.
*3, *4
SITUATIONAL
DTP Dependent Date
REQUIRED
DTP Dependent Date
REQUIRED
DTP Dependent Date
REQUIRED
Loop 2110D
EQ Eligibility or Benefit Inquiry
SITUATIONAL
Page 210 of 259
Preferred Value:
307- Eligibility
D8 CCYYMMDD
30 – Generic Request
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Pennsylvania Medicaid
Search Options
Code
*1
*2
*3
Search Option
Field 1 Search
Field 2 Search
Subscriber 1
Subscriber Member ID
Subscriber 2
Subscriber SSN
Subscriber DOB
Subscriber 3
Subscriber Last Name Subscriber First Name
Field 3 Search
Subscriber DOB
Payer Name
Payer Name
Pennsylvania Medicaid
Payer ID
PAMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
REQUIRED
NM1 Information Source Entity
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
NM101 - Entity Identifier
Code
NM102 – Entity Type
Qualifier
PR
Payer
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
PAMCD
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Provider ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
13-digit PA Provider Medicaid ID
Service Provider ID
13-digit PA Provider Medicaid ID
XX
Service Provider NPI
Service Provider NPI
SITUATIONAL
Page 211 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Submitter ID
SITUATIONAL
REF Information Receiver
Submitter ID
REF01 – Identification Code
Qualifier
Q4
REF02 – Identification Code
REF01 – Reference
Identification Qualifier
Service Provider ID
Service Provider ID
EO
Submitter ID
13-digit PA Medicaid Provider
ID.
Required and used only if the
information Receiver and the
submitter are not the same
entity.
Submitter ID
REF02 – Reference
Identification
13-digit PA Medicaid Provider
ID.
Required and used only if the
information Receiver and the
submitter are not the same
entity.
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID @
*1
NM Subscriber Member ID @
*1
REF Subscriber SSN
*2
REF Subscriber SSN
*2
NM1 Subscriber Last Name
*3
NM1 Subscriber First Name
*3
DMG Subscriber Birth Date
*2, *3
DMG Subscriber Birth Date
*2, *3
DTP Eligibility Start Date
SITUATIONAL
DTP Eligibility Start Date
NM108 – Identification
Code Qualifier
MI
Subscriber Member ID
10-digit Medicaid Recipient ID
plus 2-digit Access Card
number.
NM109 – Identification Code
Subscriber Member ID
10-digit Medicaid Recipient ID
plus 2-digit Access Card
number.
REF01 – Reference
Identification Qualifier
SY
REF02 – Reference
Identification
Subscriber SSN
Subscriber SSN
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
DMG01 – Date/Time Period
Format Qualifier
D8
Subscriber Birth Date
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
307
Eligibility Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
SITUATIONAL
Page 212 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP Eligibility Start Date
SITUATIONAL
DTP Eligibility End Date
DTP03 – Eligibility Start
Date
CCYYMMDD
DTP01 – Date/Time
Qualifier
307
Eligibility Start Date or Date
of Service Start Date is
required.
Eligibility End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Eligibility End Date Range
DTP03 – Eligibility End
Date
CCYYMMDD –
CCYYMMDD
Eligibility End Date
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
DTP01 – Date/Time
Qualifier
472
Service Start Date or
Eligibility Start Date is
required
Service End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service End Date Range
DTP03 – Service End Date
CCYYMMDD CCYYMMDD
Service End Date
30
Either Service Type Code or
Procedure Code is required.
Only supports generic
eligibility request.
OPTIONAL
DTP Eligibility End Date
OPTIONAL
DTP Eligibility End Date
OPTIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Use only if the Eligibility Start
Date span is used.
Date span cannot be more
than 31 days.
Service Start Date or
Eligibility Start Date is
required
Use only if the Date of Service
Start Date is used.
Date span cannot be more than
31 days.
Loop 2110C
EQ - Service Type Code
EQ01 - Service Type Code
SITUATIONAL
EQ – Composite Medical
Procedure Identifier
EQ02-1
Product/Service ID Qualifier
Required and used only if
Procedure Code is used.
AD = American Dental
Association codes
CJ = CPT-4 Codes
HC = HCPCS Codes
ID = ICD-9 Codes
N4 = National Drug Codes in 54-2 Format
EQ02-2
Product/Service ID
Either Service Type Code or
Procedure Code is required.
SITUATIONAL
EQ - Composite Medical
Procedure Identifier
SITUATIONAL
@Indicates field data may be obtained from the card swipe.
Page 213 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Principal Financial Group (Principal Life)
Search Options
Code
*1
*2
Search Option
Subscriber 1
Dependent 1
Field 1 Search
Subscriber Member ID
Subscriber Member ID
Field 2 Search
Subscriber DOB
Subscriber DOB
Field 3 Search
Dependent DOB
Payer Name
Payer Name
Principal Financial Group (Principal Life)
Payer ID^
61271
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
61271
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Federal Tax ID
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
FI
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
Federal Tax ID
XX
Service Provider NPI
SITUATIONAL
Page 214 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
REF01 – Identification Code
Qualifier
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
Service Provider NPI
TJ
REF02 – Identification Code
Service Provider Tax ID
Service Provider Tax ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
*1, *2
NM Subscriber Member ID
*1, *2
DMG Subscriber Birth Date
*1, *2
NM1 Subscriber Last Name
OPTIONAL
NM1 Subscriber First Name
OPTIONAL
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
NM108 – Identification Code
Qualifier
MI
NM109 – Identification
Code
DMG02 – Subscriber Birth
Date
Subscriber Member ID
Subscriber Member ID
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
Required for Subscriber search.
Service Start Date
Required for Subscriber search.
REQUIRED
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
Required for Subscriber search.
Use 41 for best results for
Dental Benefits.
SITUATTIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM Dependent Birth Date
*2
Page 215 of 259
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM Dependent Last Name
OPTIONAL
NM Dependent First Name
OPTIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
DTP Service Start Date
SITUATIONAL
Loop 2110D
EQ - Service Type Code
NM103 – Dependent Last
Name
NM104 – Dependent First
Name
DTP01 – Date/Time
Qualifier
472
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Service Start Date
CCYYMMDD
Service Start Date
Required for Dependent search.
Service Start Date
Required for Dependent search.
EQ01- Service Type Code
SITUATIONAL
Required for Dependent search.
Use 41 for best results for
Dental Benefits.
Page 216 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
QualChoice
Search Options
Code
Search
Option
Field 1 Search
Field 2 Search
Field 3
Search
*1
*2
*3
*4
Subscriber 1
Subscriber 2
Dependent 1
Dependent 2
Subscriber Member ID
Subscriber SSN
Subscriber Member ID
Subscriber SSN
Subscriber First Name
Subscriber First Name
Dependent First Name
Dependent First Name
Subscriber DOB
Subscriber DOB
Dependent DOB
Dependent DOB
Payer Name
Payer Name
QualChoice
Payer ID
35174
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Payer ID
REQUIRED
NM1 Information Source Payer ID
REQUIRED
NM101 - Entity
Identifier Code
PR
Payer
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 - Identification
Code Qualifier
PI
Payer Identification
NM109 - Identification
Code
35174
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver Entity
Identifier Code
REQUIRED
NM1 Information Receiver Entity
Identifier Code
REQUIRED
NM1 Information Receiver
Organization Name
SITUATIONAL
NM1 Information Receiver
Last Name
NM101 - Entity
Identifier code
1P
Provider
NM102 – Entity Type
Qualifier
2
1
Non-Person Entity
Person
NM103 – Organization
Name
Organization Name
NM103 – Last Name
Service Provider Last Name
SITUATIONAL
Page 217 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
First Name
NM104 – First Name
SITUATIONAL
NM1 Information Receiver
Provider Tax ID
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Provider Tax ID
NM109 – Identification
Code
SITUATIONAL
NM1 Information Receiver
Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Provider NPI
NM109 – Identification
Code
Service Provider First Name
FI
Service Provider ID
Service Provider Tax ID or NPI
is required
XX
Service Provider ID
Service Provider Tax ID or NPI
is required
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Last Name
Subscriber Last Name
NM1 Subscriber First Name
NM104 – First Name
Subscriber First Name
*1, *2
NM1 Subscriber Member ID
NM108 – Identification
Code Qualifier
MI
The Member ID can be either
the SSN or QualChoice ID.
*1, *2, *3, *4
NM1 Subscriber Member ID
NM109 – Identification
Code
Subscriber Member ID
DMG01 – Date/Time
Period Format Qualifier
D8
The Member ID can be either
the SSN or QualChoice ID.
Subscriber Birth Date Qualifier
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Period Format Qualifier
D8
Service Start Date Range
DTP03 – Eligibility Date
CCYYMMDD
Service Start Date
EQ01 – Benefit
Coverage Level Code
30
Benefit Service Type Code
*1, *2, *3, *4
DMG Subscriber Birth Date
*1, *2
DMG Subscriber Birth Date
*1, *2
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
Loop 2110C
EQ Coverage Level Code
REQUIRED
Page 218 of 259
Subscriber Member ID
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
NM1 Dependent First Name
*3, *4
DMG Dependent Birth Date
*3, *4
DMG Dependent Birth Date
*3, *4
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
Loop 2110D
EQ Coverage Level Code
REQUIRED
Page 219 of 259
NM103 – Last Name
Dependent Last Name
NM104 – First Name
Dependent First Name
DMG01 – Date/Time
Period Format Qualifier
D8
DMG02 – Dependent
Birth Date
DTP01 – Date/Time
Qualifier
CCYYMMDD
Dependent Birth Date
Qualifier
Dependent Birth Date
472
Service Start Date
DTP02 – Date/Time
Period Format Qualifier
D8
Service Start Date Range
DTP03 – Eligibility Date
CCYYMMDD
Service Start Date
EQ01 – Benefit
Coverage Level Code
30
Benefit Service Type Code
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Texas Blue Cross Blue Shield
Search Options
Code
Search Option
*1
Subscriber 1
*2
Dependent 2
Field 1 Search
Subscriber
Member ID
Subscriber
Member ID
Field 2 Search
Subscriber
Last Name
Dependent
Last Name
Field 3 Search
Subscriber
First Name
Dependent
First Name
Field 4 Search
Subscriber
DOB
Dependent
DOB
Payer Name
Payer Name
Texas Blue Cross Blue Shield
Payer ID
TXBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
REQUIRED
NM1 Information Source Entity
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM101 - Entity Identifier
Code
NM102 – Entity Type
Qualifier
PR
Payer
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
TXBLS
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Organization Name
NM101 - Entity Identifier
code
1P
Provider
NM102 – Entity Type
Qualifier
2
1
Non-Person Entity
Person
NM103 – Organization
Name
Organization Name
NM103 – First Name
Service Provider First Name
NM104 – First Name
Service Provider First Name
SITUATIONAL
NM1 Information Receiver
First Name
SITUATIONAL
NM1 Information Receiver
First Name
SITUATIONAL
NM1 Information Receiver
Service Provider ID
NM108 – Identification Code
Qualifier
SV
Service Provider ID
SITUATIONAL
Page 220 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification Code
NM108 – Identification
Code Qualifier
Service Provider ID
XX
Service Provider ID or NPI is
required.
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM109 – Identification
Code
Service Provider ID or NPI is
required.
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Last Name
*1
NM1 Subscriber First Name
NM104 – First Name
*1
NM1 Subscriber Member ID
*1, *2
NM1 Subscriber Member ID
*1, *2
DMG Subscriber Birth Date
*1
DMG Subscriber Birth Date
*1
Loop 2110C
EQ - Service Type Code
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
Subscriber Member ID
Subscriber Member ID
DMG01 – Date/Time Period
Format Qualifier
D8
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
EQ01- Service Type Code
30
Benefit Service Type Code
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
*2
NM1 Dependent First Name
*2
DMG Dependent Birth Date
*2
DMG Dependent Birth Date
*2
Loop 2110D
EQ - Service Type Code
NM103 – Last Name
NM104 – First Name
DMG01 – Date/Time Period
Format Qualifier
DMG02 – Dependent Birth
Date
D8
Dependent Birth Date
CCYYMMDD
Dependent Birth Date
EQ01- Service Type Code
30
Benefit Service Type Code
SITUATIONAL
Page 221 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Texas Medicaid
Search Options
Code
*1
*2
*3
*4
Search Option
Subscriber 1
Subscriber 2
Subscriber 3
Subscriber 4
Field 1 Search
Field 2 Search
Subscriber Member ID
Subscriber Last Name
Subscriber SSN
Subscriber Last Name Subscriber First Name
Subscriber SSN
Subscriber Birth Date
Field 3 Search
Subscriber Birth Date
Payer Name
Payer Name
Texas Medicaid
Payer ID
TXMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
REQUIRED
NM1 Information Source Entity
REQUIRED
NM1 Information Source
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM101 - Entity Identifier
Code
PR
Payer
NM102 – Entity Type
Qualifier
NM108 - Identification Code
Qualifier
2
Non-Person Entity
PI
Payer Identification
NM109 - Identification Code
TXMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
NM101 - Entity Identifier
Code
1P
Provider
NM102 – Entity Type
Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider Number
NM109 – Identification
Code
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM108 – Identification
Code Qualifier
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM109 – Identification
Code
Page 222 of 259
Service Provider Number
XX
Service Provider NPI
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF01 – Identification Code
Qualifier
Q4
REF02 – Identification Code
Service Provider ID
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*2, *3
NM1 Subscriber First Name
*3
NM Subscriber Member ID
*1
NM Subscriber Member ID
*1
REF Subscriber SSN
*2, *4
REF Subscriber SSN
*2, *4
DMG Subscriber Birth Date
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
NM108 – Identification Code
Qualifier
MI
NM109 – Identification
Code
REF01 – Reference
Identification Qualifier
Subscriber Member ID
Subscriber Member ID
SY
REF02 – Reference
Identification
Social Security Number
Social Security Number
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service Start Date Range
DTP03 – Service Start Date
CCYYMMDD –
CCYYMMDD
Service Start Date
DTP01 – Date/Time
Qualifier
472
Service End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service End Date Range
REQUIRED
DTP Service End Date
DTP03 – Service Start Date
CCYYMMDD –
CCYYMMDD
Service End Date
REQUIRED
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
30
Texas Medicaid only supports a
general benefit search.
*3, *4
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service End Date
REQUIRED
DTP Service End Date
REQUIRED
Page 223 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Three Rivers Health Plan
Search Options Not Applicable.
Payer Name
Payer Name
Three Rivers Health Plans
Payer ID ^
00199
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
00199
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
Page 224 of 259
NM101 - Entity Identifier Code
NM102 – Entity Type Qualifier
NM108 – Identification Code
Qualifier
1P = Provider
80 = Hospital
FA = Facility
2
SV
NM109 – Identification Code
NM108 – Identification Code
Qualifier
NM109 – Identification Code
Service Provider ID, Tax ID, or
NPI is required.
Service Provider ID, Tax ID, or
NPI is required.
FI
NM109 – Identification Code
NM108 – Identification Code
Qualifier
Non-Person Entity
Service Provider ID, Tax ID, or
NPI is required.
Service Provider ID, Tax ID, or
NPI is required.
XX
Service Provider ID, Tax ID, or
NPI is required.
Service Provider ID, Tax ID, or
NPI is required.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver Plan
Network ID
SITUATIONAL
REF Information Receiver Plan
Network ID
SITUATIONAL
REF Information Receiver
Facility Network ID
SITUATIONAL
REF Information Receiver
Facility Network ID
REF01 – Identification Code
Qualifier
TJ
REF02 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider Tax ID
Q4
REF02 – Identification Code
REF01 – Reference
Identification Qualifier
Service Provider ID
Service Provider ID
N5
REF02 – Reference
Identification
REF01 – Reference
Identification Qualifier
Service Provider Tax ID
Provider Plan Network
Identification Number or Facility
Network ID is required.
N7
REF02 – Reference
Identification
Facility Network Identification
Number or Provider Plan
Network Identification Number is
required.
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
REQUIRED
NM Subscriber Member ID
REQUIRED
REF Subscriber
Patient Account Number
OPTIONAL
REF Subscriber
Patient Account Number
OPTIONAL
NM1 Subscriber Last Name
REQUIRED
NM1 Subscriber First Name
REQUIRED
DMG Subscriber Birth Date
REQUIRED
DTP Eligibility Start Date
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
REF01 – Reference
Identification Qualifier
Subscriber Member ID
Subscriber Member ID
EJ
REF02 – Reference
Identification
Subscriber Patient Account
Number
Subscriber Patient Account
Number
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time Qualifier
307
Eligibility Start Date
REQUIRED
Page 225 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP02 – Date/Time Period
Format Qualifier
D8
REQUIRED
DTP Eligibility Start Date
DTP03 – Eligibility Start Date
CCYYMMDD
Eligibility Start Date
REQUIRED
DTP Eligibility End Date
DTP01 – Date/Time Qualifier
307
Eligibility End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Eligibility Date Range
OPTIONAL
DTP Eligibility End Date
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Eligibility End Date Range
OPTIONAL
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
DTP Eligibility Start Date
OPTIONAL
DTP Eligibility End Date
REQUIRED
Page 226 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Three Rivers Health Plan / Unison MedPLUS (Medicaid)
Search Options Not Applicable.
Payer Name
Payer Name ^
Three Rivers Health Plans / Unison MedPLUS (Medicaid)
Payer ID ^
00198
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
NM101 - Entity Identifier Code
PR
Payer
REQUIRED
NM1 Information Source Name
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
00198
Carrier ID
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Federal Tax ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
NM101 - Entity Identifier Code
NM102 – Entity Type Qualifier
NM108 – Identification Code
Qualifier
1P = Provider
80 = Hospital
FA = Facility
2
SV
NM109 – Identification Code
NM108 – Identification Code
Qualifier
Service Provider ID, Tax ID, or
NPI is required.
Service Provider ID, Tax ID, or
NPI is required.
FI
NM109 – Identification Code
NM108 – Identification Code
Qualifier
Non-Person Entity
Service Provider ID, Tax ID, or
NPI is required.
Service Provider ID, Tax ID, or
NPI is required.
XX
Service Provider ID, Tax ID, or
NPI is required.
SITUATIONAL
Page 227 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider Tax ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver Plan
Network ID
SITUATIONAL
REF Information Receiver Plan
Network ID
SITUATIONAL
REF Information Receiver
Facility Network ID
SITUATIONAL
REF Information Receiver
Facility Network ID
NM109 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider ID, Tax ID, or
NPI is required.
TJ
REF02 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider Tax ID
Q4
REF02 – Identification Code
REF01 – Reference
Identification Qualifier
Service Provider ID
Service Provider ID
N5
REF02 – Reference
Identification
REF01 – Reference
Identification Qualifier
Service Provider Tax ID
Provider Plan Network
Identification Number or Facility
Network ID is required.
N7
REF02 – Reference
Identification
Facility Network Identification
Number or Provider Plan
Network Identification Number is
required.
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
NM108 – Identification Code
Qualifier
REQUIRED
NM Subscriber Member ID
NM109 – Identification Code
REQUIRED
REF Subscriber
Patient Account Number
REF01 – Reference
Identification Qualifier
OPTIONAL
REF Subscriber
Patient Account Number
REF02 – Reference
Identification
OPTIONAL
NM1 Subscriber Last Name
REQUIRED
NM1 Subscriber First Name
REQUIRED
DMG Subscriber Birth Date
REQUIRED
Page 228 of 259
MI
Subscriber Member ID
Subscriber Member ID
EJ
Subscriber Patient Account
Number
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
D8
REQUIRED
DTP Eligibility Start Date
DTP03 – Eligibility Start Date
CCYYMMDD
Eligibility Start Date
REQUIRED
DTP Eligibility End Date
DTP01 – Date/Time Qualifier
307
Eligibility End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Eligibility Date Range
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Eligibility End Date Range
DTP Eligibility Start Date
REQUIRED
DTP Eligibility Start Date
OPTIONAL
DTP Eligibility End Date
OPTIONAL
DTP Eligibility End Date
Eligibility Start Date
OPTIONAL
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
REQUIRED
Page 229 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
TRICARE (Champus)
Search Options
Code
*1
*2
Search
Option
Field 1
Search
Subscriber
Subscriber Member ID
Subscriber
Dependent Member ID
Field 2
Search
Subscriber
Last Name
Subscriber
Last Name
Field 3
Search
Subscriber
First Name
Subscriber
First Name
Field 4
Search
Subscriber
DOB
Dependent
Last Name
Field 5
Search
Field 6
Search
Dependent Dependent
First Name
DOB
Payer Name
Payer Name
TRICARE (Champus)
Payer ID ^
00080
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
00080
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
Page 230 of 259
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider Number
NM109 – Identification Code
NM108 – Identification Code
Qualifier
NM109 – Identification Code
Service Provider Number
XX
Service Provider NPI
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF01 – Identification Code
Qualifier
Q4
REF02 – Identification Code
Service Provider ID
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*1, *2
NM1 Subscriber First Name
*1, *2
NM Subscriber Member ID
*1, *2
NM Subscriber Member ID
*1, *2
DMG Subscriber Birth Date
*1
DTP Eligibility Start Date
OPTIONAL
DTP Eligibility Start Date
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
Subscriber Member ID
Subscriber Member ID
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time Qualifier
307
Eligibility Start Date
Optional the default value is the
current date.
DTP02 – Date/Time Period
Format Qualifier
RD8
Eligibility Date Range
DTP03 – Service Start Date
CCYYMMDD –
CCYYMMDD
Eligibility Start Date
DTP01 – Date/Time Qualifier
307
Eligibility End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Eligibility Date Range
DTP03 – Date/Time Period
Format Qualifier
CCYYMMDD CCYYMMDD
Eligibility End Date
EQ01- Service Type Code
30
Required for Subscriber
search.
OPTIONAL
DTP Eligibility Start Date
OPTIONAL
DTP Eligibility End Date
OPTIONAL
DTP Eligibility End Date
OPTIONAL
DTP Service End Date
OPTIONAL
Loop 2110C
EQ - Service Type Code
SITUATIONAL
Optional the default value is the
current date.
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
Page 231 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM Dependent Last Name
*2
NM Dependent First Name
*2
NM Dependent Birth Date
NM103 – Dependent Last
Name
NM104 – Dependent First
Name
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
Eligibility Start Date
Optional the default value is
the current date.
Eligibility Start Date Range
REQUIRED
DTP Eligibility Start Date
DTP03 – Eligibility Start Date
CCYYMMDD –
CCYYMMDD
REQUIRED
DTP Service End Date
DTP01 – Date/Time Qualifier
307
Eligibility Start Date Range
Optional the default value is
the current date.
Service End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service End Date Range
OPTIONAL
DTP Service End Date
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Service End Date Range
OPTIONAL
Loop 2110D
EQ - Service Type Code
EQ01- Service Type Code
30
Required for Dependent
search.
*2
DTP Eligibility Start Date
REQUIRED
DTP Eligibility Start Date
OPTIONAL
DTP Service End Date
REQUIRED
Page 232 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Tufts Health Plan
Search Options Not Applicable.
Payer Name
Payer Name
Tufts Health Plan
Payer ID ^
04298
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
04298
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
Page 233 of 259
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
NM109 – Identification Code
Service Provider ID
Provider ID should be 6 or 10
charters.
NM108 – Identification Code
Qualifier
XX
NM109 – Identification Code
REF01 – Identification Code
Qualifier
REF02 – Identification Code
Service Provider NPI
Service Provider NPI
Q4
Service Provider ID
Service Provider ID
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Member ID
REQUIRED
NM1 Subscriber Member ID
REQUIRED
DMG Subscriber Birth Date
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
Subscriber Member ID
Subscriber Member ID
DMG02 – Subscriber Birth
Date
CCMMYYDD
Subscriber Birth Date
DTP01 – Date/Time Qualifier
472
Service Start Date
No future date.
DTP02 – Date/Time Format
Qualifier
D8
REQUIRED
DTP Service Start Date
DTP03 – Service Start Date
CCYYMMDD
REQUIRED
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
30
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
Service Start Date
No future date.
REQUIRED
Page 234 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
UMR Wausau
Search Options
Code
Search
Option
*1
Subscriber 1
*2
*3
Subscriber 2
Subscriber 3
*4
Subscriber 4
*5
Subscriber 5
*6
Dependent 6
*7
*8
Dependent 7
Dependent 8
*9
*10
Field 1 Search
Field 2 Search
Field 3 Search
Subscriber
Member ID
Subscriber
Member ID
Subscriber SSN
Subscriber
Last Name
Subscriber
Member ID
Subscriber
Member ID
Dependent DOB
Dependent 9
Subscriber
Member ID
Subscriber SSN
Dependent
Last Name
Dependent
Last Name
Dependent DOB
Dependent
First Name
Dependent DOB
Dependent 10
Subscriber
Member ID
Dependent
Last Name
Dependent
First Name
Subscriber DOB
Subscriber
Last Name
Subscriber DOB
Subscriber
First Name
Subscriber
Last Name
Field 4 Search
Subscriber
First Name
Subscriber DOB
Subscriber
First Name
Subscriber DOB
Dependent
First Name
Dependent DOB
Payer Name
Payer Name
UMR Wausau
Payer ID
39026
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM1 Information Source
Payer ID
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
PI
Payer Identification
NM109 - Identification Code
39026
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
Page 235 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Organization Name
NM101 - Entity Identifier code
1P
Provider
NM102 – Entity Type Qualifier
2
1
Non-Person Entity
Person
NM103 – Organization Name
Organization Name
SITUATIONAL
NM1 Information Receiver
Last Name
NM103 – Last Name
Service Provider Last Name
SITUATIONAL
NM1 Information Receiver
First Name
NM104 – First Name
Service Provider First Name
SITUATIONAL
NM1 Information Receiver
Provider ID
SITUATIONAL
NM1 Information Receiver
Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
NM108 – Identification Code
Qualifier
SV
NM109 – Identification Code
NM108 – Identification Code
Qualifier
Service Provider ID
XX
NM109 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider ID
Service Provider ID, Tax ID, or
NPI is required.
Service Provider ID, Tax ID, or
NPI is required.
Q4
REF02 – Identification Code
Service Provider ID
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Last Name
Subscriber Last Name
*2, *4, *5
NM1 Subscriber First Name
NM104 – First Name
Subscriber First Name
*2, *4, *5
NM1 Subscriber Member ID
*1, *2, *5, *6, *7, *10
NM1 Subscriber Member ID
NM108 – Identification Code
Qualifier
NM109 – Identification Code
MI
Subscriber Member ID
Subscriber Member ID
*1, *2, *5, *6, *7, *10
Page 236 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
REF01 – Reference
Identification Qualifier
REF Subscriber Social
Security Number
*3, *8
REF Subscriber Social
SY
REF02 – Reference
Identification
Security Number
*3, *8
DMG Subscriber Birth Date
*1, *3,*4, *5
DMG Subscriber Birth Date
*1, *3,*4, *5
Loop 2110C
EQ Coverage Level Code
Subscriber Social Security
Number
Subscriber Social Security
Number
DMG01 – Date/Time Period
Format Qualifier
D8
CCYYMMDD
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
EQ01 – Benefit Coverage
Level Code
See
Supported
Service
Types below.
Benefit Service Type Code
REQUIRED if subscriber is
the patient.
Supported Service Types:
1, 30, 33, 34, 35, 48, 50, 52, 86, 88, 98, 99, A0, A4, A7, A8, AL, AM, AN, AO, BB
Loop 2100D – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
NM103 – Last Name
Dependent Last Name
NM104 – First Name
Dependent First Name
*7, *9, *10
NM1 Dependent First Name
*7, *9, *10
DMG Dependent Birth Date
*6, *8, *9, *10
DMG01 – Date/Time Period
Format Qualifier
D8
CCYYMMDD
Dependent Birth Date
DMG Dependent Birth Date
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
EQ01 – Benefit Coverage
Level Code
See
Supported
Service
Types below.
Benefit Service Type Code
*6, *8, *9, *10
Loop 2110D
EQ Coverage Level Code
REQUIRED if dependent is
the patient.
Supported Service Types:
1, 30, 33, 34, 35, 48, 50, 52, 86, 88, 98, 99, A0, A4, A7, A8, AL, AM, AN, AO, BB
Page 237 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
UniCare (WellPoint Health Network)
Search Options
Code
*1
*2
Search
Option
Field 1
Search
Subscriber
Subscriber Last Name
Subscriber
Dependent Last Name
Field 2
Field 3
Field 4
Field 5
Field 6
Search
Search
Search
Search
Search
Subscriber Subscriber Subscriber Subscriber
First Name
DOB
Member ID
Gender
Subscriber Subscriber Dependent Dependent Dependent
First Name Member ID Last Name First Name
DOB
Field 7
Search
Dependent
Gender
Payer Name
Payer Name
UniCare
Payer ID ^
UNI
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
UNI
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
NM1 Information Receiver
Provider ID
REQUIRED
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
Page 238 of 259
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification Code
Qualifier
SV
XX
Provider ID
NPI
NM109 – Identification Code
REF01 – Identification Code
Qualifier
REF02 – Identification Code
If NM108 is equal to SV,
segment should be Provider ID.
Q4
If NM108 is equal to XX,
segment should be NPI.
Service Provider ID
Service Provider ID
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
REQUIRED
NM Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
*1
SITUATIONAL
NM1 Subscriber First Name
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DTP Eligibility Date
NM108 – Identification Code
Qualifier
MI
Subscriber Member ID
NM109 – Identification Code
Subscriber Member ID
NM103 – Subscriber Last
Name
Required for Subscriber Search.
NM104 – Subscriber First
Name
Required for Subscriber Search.
DMG01 – Subscriber Birth
Date
D8
DMG02 – Subscriber Birth
Date
CCYYMMDD
Date expressed as
CCYYMMDD.
Required for Subscriber Search.
Required for Subscriber Search.
DTP01 – Date/Time Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
EQ - Service Type Code
EQ01- Service Type Code
30
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110C
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Eligibility
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
*2
SITUATIONAL
Page 239 of 259
NM103 – Dependent Last
Name
Required for Dependent Search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Dependent First Name
*2
SITUATIONAL
DMG Dependent Birth Date
*2
SITUATIONAL
DMG Dependent Birth Date
*2
SITUATIONAL
DTP Eligibility Date
NM104 – Dependent First
Name
Required for Dependent Search.
DMG01 – Dependent Birth
Date
D8
Date expressed as
CCYYMMDD.
Required for Dependent Search.
DMG02 – Dependent Birth
Date
CCYYMMDD
Required for Dependent Search.
DTP01 – Date/Time Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
Loop 2110D
DTP Eligibility Date
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
EQ - Service Type Code
EQ01- Service Type Code
30
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Eligibility
SITUATIONAL
Page 240 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
UnitedHealthcare
Search Options
Code
*1
*2
*3
*4
*5
*6
*7
*8
*9
*10
*11
*12
Search
Option
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Subscriber 1
Subscriber 2
Subscriber 3
Subscriber 4
Subscriber 5
Subscriber 6
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dependent 6
Subscriber Member ID
Subscriber Member ID
Subscriber Member ID
Subscriber Member ID
Subscriber Member ID
Subscriber Last Name
Subscriber Last Name
Subscriber First Name
Subscriber DOB
Subscriber DOB
Subscriber DOB
Subscriber DOB
Subscriber First Name
Subscriber Last Name Subscriber First Name
Subscriber Last Name Subscriber First Name
Subscriber Member ID Dependent Last Name Dependent First Name
Subscriber Member ID Dependent Last Name
Subscriber Member ID
Dependent First Name
Subscriber Member ID
Subscriber Member ID Dependent Last Name Dependent First Name
Dependent Last Name Dependent First Name
Subscriber DOB
Dependent DOB
Dependent DOB
Dependent DOB
Subscriber DOB
Dependent DOB
Payer Name
Payer Name
UnitedHealthcare
Payer ID
87726 or UHC
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source
REQUIRED
NM1 Information Source
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
87726
UHC
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
NM101 - Entity Identifier code
1P
Provider
REQUIRED
NM1 Information Receiver
Entity Identifier Code
NM102 – Entity Type Qualifier
2
1
Non-Person Entity
Person
REQUIRED
Page 241 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM103 – Organization Name
Organization Name
SITUATIONAL
NM1 Information Receiver
First Name
NM103 – First Name
Service Provider First Name
SITUATIONAL
NM1 Information Receiver
First Name
NM104 – First Name
Service Provider First Name
NM1 Information Receiver
Organization Name
SITUATIONAL
NM1 Information Receiver
Provider ID
SITUATIONAL
NM1 Information Receiver
Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
NM108 – Identification Code
Qualifier
SV
NM109 – Identification Code
NM108 – Identification Code
Qualifier
Service Provider ID
XX
NM109 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider ID
Service Provider ID, Tax ID, or
NPI is required.
Service Provider ID, Tax ID, or
NPI is required.
Q4
REF02 – Identification Code
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes Specific
to ICS
MI
Subscriber Member ID
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Last Name
*1, *2, *5, *6
NM1 Subscriber First Name
NM104 – First Name
*1, *3, *5, *6
NM1 Subscriber Middle Name
NM105 – Middle Name
OPTIONAL
NM1 Subscriber Member ID
NM108 – Identification Code
Qualifier
*1, *2, *3, *4, *5,
*7, *8, *9, *10, *11
Page 242 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Subscriber Member ID
NM109 – Identification Code
*1, *2, *3, *4, *5,
*7, *8, *9, *10, *11
REF Subscriber
Group Number
REF01 – Reference
Identification Qualifier
OPTIONAL
REF Subscriber
Group Number
REF02 – Reference
Identification
OPTIONAL
DMG Subscriber Birth Date
Subscriber Member ID
6P
Subscriber Group Number
Subscriber Group Number
DMG01 – Date/Time Period
Format Qualifier
D8
DMG02 – Subscriber Birth
Date
CCYYMMDD
DMG03 – Subscriber Gender
Code
F = Female
M = Male
DTP01 – Date/Time Qualifier
472
DTP02 – Date/Time Period
Format Qualifier
RD8
REQUIRED
DTP Service Start Date
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Service Start Date
REQUIRED
DTP Service End Date
DTP01 – Date/Time Qualifier
472
Service End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service End Date Range
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Service End Date Range
*1, *2, *3, *4, *6
DMG Subscriber Birth Date
*1, *2, *3, *4, *6
DMG Subscriber Gender
OPTIONAL
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service End Date
REQUIRED
DTP Service End Date
REQUIRED
Loop 2110C
EQ Coverage Level Code
OPTIONAL
Service Start Date
Service Start Date Range
EQ03 – Benefit Coverage
Level Code
Benefit Coverage Level Code
EQ04 – Insurance Type Code
Insurance Type Code
OPTIONAL
EQ Insurance Type Code
Subscriber Birth Date
Refer to the 270 HIPAA
Implementation Guide for
applicable qualifiers.
Refer to the 270 HIPAA
Implementation Guide for
applicable qualifiers.
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
Page 243 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Dependent Last Name
NM103 – Last Name
*7, *8, *11, *12
NM1 Dependent First Name
NM104 – First Name
*7, *9, *11, *12
NM1 Dependent Middle Name
OPTIONAL
DMG Dependent Birth Date
NM105 – Middle Name
DMG01 – Date/Time Period
Format Qualifier
D8
Dependent Birth Date
DMG02 – Dependent Birth
Date
CCYYMMDD
Dependent Birth Date
*7, *8, *9, *10, *12
DMG Dependent Gender
DMG03 – Gender Code
F = Female
M = Male
Dependent Gender Code
OPTIONAL
DTP Service Start Date
DTP01 – Date/Time Qualifier
472
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service Start Date Range
REQUIRED
DTP Service Start Date
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Service Start Date
REQUIRED
DTP Service End Date
DTP01 – Date/Time Qualifier
472
Service End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service End Date Range
DTP03 – Service End Date
CCYYMMDD CCYYMMDD
Service End Date
*7, *8, *9, *10, *12
DMG Dependent Birth Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service End Date
REQUIRED
DTP Service End Date
REQUIRED
Loop 2110D
EQ Benefit Coverage Level
Code
EQ03 – Coverage Level Code
Refer to the 270 HIPAA
Implementation Guide for
applicable qualifiers.
OPTIONAL
EQ Insurance Type Code
OPTIONAL
Page 244 of 259
Benefit Coverage Level Code
EQ04 – Insurance Type Code
Insurance Type Code
Refer to the 270 HIPAA
Implementation Guide for
applicable qualifiers.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Virginia Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Code
*1
*2
Search
Option
Field 1
Search
Subscriber
Subscriber Last Name
Subscriber
Dependent Last Name
Field 2
Field 3
Field 4
Field 5
Field 6
Search
Search
Search
Search
Search
Subscriber Subscriber Subscriber Subscriber
First Name
DOB
Member ID
Gender
Subscriber Subscriber Dependent Dependent Dependent
First Name Member ID Last Name First Name
DOB
Field 7
Search
Dependent
Gender
Payer Name
Payer Name
Virginia Blue Cross Blue Shield
Payer ID ^
VABLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
VABLS
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
Page 245 of 259
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification Code
Qualifier
SV
XX
Provider ID
NPI
Q4
If NM108 is equal to SV,
segment should be Provider ID.
If NM108 is equal to XX,
segment should be NPI.
Service Provider ID
NM109 – Identification Code
REF01 – Identification Code
Qualifier
REF02 – Identification Code
Service Provider ID
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
REQUIRED
NM Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
*1
SITUATIONAL
NM1 Subscriber First Name
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DMG Subscriber Birth Date
NM108 – Identification Code
Qualifier
MI
Subscriber Member ID
NM109 – Identification Code
Subscriber Member ID
NM103 – Subscriber Last
Name
Required for Subscriber Search.
NM104 – Subscriber First
Name
Required for Subscriber Search.
DMG01 – Subscriber Birth
Date
D8
Date expressed as
CCYYMMDD.
DMG02 – Subscriber Birth
Date
CCYYMMDD
Required for Subscriber Search.
Required for Subscriber Search.
DTP01 – Date/Time Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
Loop 2110C
EQ - Service Type Code
EQ01- Service Type Code
30
*1
SITUATIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
*2
SITUATIONAL
NM1 Dependent First Name
*2
SITUATIONAL
DMG Dependent Birth Date
*2
SITUATIONAL
DMG Dependent Birth Date
*2
SITUATIONAL
Page 246 of 259
NM103 – Dependent Last
Name
Required for Dependent Search.
NM104 – Dependent First
Name
Required for Dependent Search.
DMG01 – Dependent Birth
Date
D8
DMG02 – Dependent Birth
Date
CCYYMMDD
Date expressed as
CCYYMMDD.
Required for Dependent Search.
Required for Dependent Search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
OPTIONAL
DTP Eligibility Date
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
OPTIONAL
Loop 2110D
EQ - Service Type Code
EQ01- Service Type Code
30
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
Eligibility
SITUATIONAL
Page 247 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Virginia Medicaid
Search Options
Code
*1
*2
*3
*4
Search Option
Subscriber 1
Subscriber 2
Subscriber 3
Subscriber 4
Field 1 Search
Field 2 Search
Field 3 Search
Subscriber Member ID
Subscriber SSN
Subscriber DOB
Subscriber SSN
Subscriber Last Name Subscriber First Name
Subscriber DOB
Subscriber Last Name Subscriber First Name
Payer Name
Payer Name
Virginia Medicaid
Payer ID
VAMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source
REQUIRED
NM1 Information Source
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
VAMCD
Carrier ID
REQUIRED
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
Page 248 of 259
NM101 - Entity Identifier code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider Number
NM109 – Identification Code
NM108 – Identification Code
Qualifier
NM109 – Identification Code
Service Provider Number
XX
Service Provider NPI
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
REF01 – Identification Code
Qualifier
Q4
REF02 – Identification Code
Service Provider ID
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
*1
NM Subscriber Member ID
*1
REF Subscriber SSN
*2, *3
REF Subscriber SSN
*2, *3
DMG Subscriber Birth Date
*2, *4
NM1 Subscriber Last Name
*3, *4
NM1 Subscriber First Name
*3, *4
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service Start Date
REQUIRED
DTP Service End Date
REQUIRED
DTP Service End Date
REQUIRED
DTP Service End Date
REQUIRED
Loop 2110C
EQ - Service Type Code
REQUIRED
Page 249 of 259
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
REF01 – Reference
Identification Qualifier
Subscriber Member ID
SY
REF02 – Reference
Identification
DMG02 – Subscriber Birth
Date
Subscriber Member ID
Social Security Number
Social Security Number
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time Qualifier
472
Service Start Date
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Service Start Date
DTP01 – Date/Time Qualifier
472
Service End Date
DTP02 – Date/Time Period
Format Qualifier
RD8
Service End Date Range
DTP03 – Service Start Date
CCYYMMDD CCYYMMDD
Service End Date Range
EQ01- Service Type Code
11, 12, 18, 30,
42, 43, A8, AD,
AE, AF, AI, AL,
or AO
VA Medicaid will process all
Service Type Codes, other
than those listed, as 30.
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
Service Start Date Range
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
WEA Trust
Search Options
Code
Search
Option
*1
Subscriber 1
*2
Dependent 1
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Subscriber
Last Name
Subscriber
Last Name
Subscriber
First Name
Subscriber
First Name
Subscriber
Member ID (SSN)
Subscriber
Member ID (SSN)
Subscriber
DOB
Dependent
Last Name
Dependent
First Name
Dependent
DOB
Payer Name
Payer Name
WEA Trust
Payer ID
CALL
Loop 2100A – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100A
NM1 Information Source
NM101 - Entity Identifier PR
Payer
Entity Identifier Code
Code
REQUIRED
NM1 Information Source
NM102 – Entity Type
2
Non-Person Entity
Entity Identifier Code
Qualifier
REQUIRED
NM1 Information Source
NM108 - Identification
PI
Payer Identification
Payer ID
Code Qualifier
REQUIRED
NM1 Information Source
NM109 - Identification
CALL
Carrier ID
Contact Rick Hammes,
Payer ID
Code
rhammes@weatrust.com,
REQUIRED
prior to submission for
Payer ID and approval
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Segment
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
NM101 - Entity Identifier 1P
Provider
Entity Identifier Code
code
REQUIRED
NM1 Information Receiver
NM102 – Entity Type
2
Non-Person Entity
1
Person
Entity Identifier Code
Qualifier
REQUIRED
NM1 Information Receiver
NM103 – Organization
Organization Name
Organization Name
Name
SITUATIONAL
NM1 Information Receiver
Last Name
NM103 – Last Name
Service Provider Last Name
SITUATIONAL
Page 250 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
First Name
NM104 – First Name
SITUATIONAL
NM1 Information Receiver
Provider NPI
NM108 – Identification
Code Qualifier
REQUIRED
NM1 Information Receiver
Provider NPI
NM109 – Identification
Code
Service Provider First Name
XX
Service Provider ID
Service Provider NPI is
required
REQUIRED
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
NM103 – Last Name
Subscriber Last Name
*1, *2
NM1 Subscriber First Name
NM104 – First Name
Subscriber First Name
*1, *2
NM1 Subscriber Member ID
*1, *2
NM1 Subscriber Member ID
*1, *2
DMG Subscriber Birth Date
*1
DMG Subscriber Birth Date
*1
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
Loop 2110C
EQ Coverage Level Code
REQUIRED
NM108 – Identification
Code Qualifier
MI
NM109 – Identification
Code
Subscriber Member ID
Subscriber Member ID
DMG01 – Date/Time
Period Format Qualifier
D8
WEA Trust uses the Member
Social Security Number as the
Member ID.
Subscriber Birth Date Qualifier
DMG02 – Subscriber
Birth Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Period Format Qualifier
D8
Service Start Date Range
DTP03 – Eligibility Date
CCYYMMDD
Service Start Date
EQ01 – Benefit
Coverage Level Code
30
Benefit Service Type Code
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes
Specific to ICS
Designator(s)
Page 251 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100D
NM1 Dependent Last Name
NM103 – Last Name
Dependent Last Name
*2
NM1 Dependent First Name
NM104 – First Name
Dependent First Name
*2
DMG Dependent Birth Date
*2
DMG Dependent Birth Date
*2
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
DTP Eligibility Date
REQUIRED
Loop 2110D
EQ Coverage Level Code
REQUIRED
DMG01 – Date/Time
Period Format Qualifier
D8
DMG02 – Dependent
Birth Date
CCYYMMDD
Dependent Birth Date
Qualifier
Dependent Birth Date
DTP01 – Date/Time
Qualifier
472
Service Start Date
DTP02 – Date/Time
Period Format Qualifier
D8
Service Start Date Range
DTP03 – Eligibility Date
CCYYMMDD
Service Start Date
EQ01 – Benefit
Coverage Level Code
30
Benefit Service Type Code
Wisconsin Anthem Blue Cross Blue Shield (WellPoint Health Network)
Search Options
Code
Search
Option
Page 252 of 259
Field 1
Search
Field 2
Search
Field 3
Search
Field 4
Search
Field 5
Search
Field 6
Search
Field 7
Search
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
*1
*2
Subscriber
Last Name
Subscriber
Dependent Last Name
Subscriber
Subscriber Subscriber Subscriber Subscriber
First Name
DOB
Member ID
Gender
Subscriber Subscriber Dependent Dependent Dependent
First Name Member ID Last Name First Name
DOB
Dependent
Gender
Payer Name
Payer Name
Wisconsin Blue Cross Blue Shield
Payer ID ^
WIBLS
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
WIBLS
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
NM1 Information Receiver
Provider ID
REQUIRED
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
NM101 - Entity Identifier Code
1P
Provider
NM102 – Entity Type Qualifier
1
2
Person (Providers)
Non-Person Entity (Facility)
NM108 – Identification Code
Qualifier
SV
XX
Provider ID
NPI
Q4
If NM108 is equal to SV,
segment should be Provider ID.
If NM108 is equal to XX,
segment should be NPI.
Service Provider ID
NM109 – Identification Code
REF01 – Identification Code
Qualifier
REF02 – Identification Code
Service Provider ID
SITUATIONAL
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
Page 253 of 259
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Loop 2100C
NM Subscriber Member ID
REQUIRED
NM Subscriber Member ID
REQUIRED
NM1 Subscriber Last Name
*1
SITUATIONAL
NM1 Subscriber First Name
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DMG Subscriber Birth Date
*1
SITUATIONAL
DMG Subscriber Gender
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110C
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
EQ - Service Type Code
NM108 – Identification Code
Qualifier
MI
Subscriber Member ID
NM109 – Identification Code
Subscriber Member ID
NM103 – Subscriber Last
Name
Required for Subscriber Search.
NM104 – Subscriber First
Name
Required for Subscriber Search.
DMG01 – Subscriber Birth
Date
D8
Required for Subscriber Search.
DMG02 – Subscriber Birth
Date
CCYYMMDD
Required for Subscriber Search.
DMG03 – Subscriber Gender
Code
M
F
Male
Female
DTP01 – Date/Time Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
EQ01- Service Type Code
30
Eligibility
SITUATIONAL
Loop 2100D – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100D
NM1 Dependent Last Name
*2
SITUATIONAL
NM1 Dependent First Name
*2
SITUATIONAL
DMG Dependent Birth Date
*2
SITUATIONAL
Page 254 of 259
NM103 – Dependent Last
Name
Required for Dependent Search.
NM104 – Dependent First
Name
Required for Dependent Search.
DMG01 – Dependent Birth
Date
D8
Required for Dependent Search.
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DMG Dependent Birth Date
*2
SITUATIONAL
DMG02 – Dependent Birth
Date
CCYYMMDD
Required for Dependent Search.
DMG Dependent Gender
DMG02 – Dependent Gender
Code
M
F
Male
Female
DTP01 – Date/Time Qualifier
307
Eligibility
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
DTP01 – Date/Time Qualifier
307
DTP02 – Date/Time Period
Format Qualifier
RD8
DTP03 – Eligibility Date
CCYYMMDDCCYYMMDD
EQ01- Service Type Code
30
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
Loop 2110D
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
DTP Eligibility Date
OPTIONAL
EQ - Service Type Code
Eligibility
SITUATIONAL
Page 255 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Wisconsin Medicaid
Search Options
Code
*1
*2
*3
*4
*5
Search Option
Subscriber 1
Subscriber 2
Subscriber 3
Subscriber 4
Subscriber 5
Field 1 Search
Field 2 Search
Field 3 Search
Subscriber Member ID
Subscriber SSN
Subscriber DOB
Subscriber SSN
Subscriber Last Name Subscriber First Name
Subscriber Last Name
Subscriber First Name
Subscriber DOB
Subscriber ID Card Number @
Payer Name
Payer Name
Wisconsin Medicaid
Payer ID
WIMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
WIMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
Page 256 of 259
NM101 - Entity Identifier code
1P
Provider
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Service Provider Number
NM109 – Identification Code
NM108 – Identification Code
Qualifier
Service Provider Number
XX
Service Provider NPI
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
NM109 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider NPI
Q4
REF02 – Identification Code
Service Provider ID
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM Subscriber Member ID
NM108 – Identification Code
Qualifier
*1
NM Subscriber Member ID
NM109 – Identification Code
*1
REF Subscriber
ID Card Number @
REF01 – Reference
Identification Qualifier
*5
REF Subscriber
ID Card Number @
REF02 – Reference
Identification
*5
REF Subscriber SSN
*2, *3
REF Subscriber SSN
*2, *3
NM1 Subscriber Last Name
*3, *4
NM1 Subscriber First Name
*3, *4
DMG Subscriber Birth Date
*2, *4
DTP Eligibility Start Date
REQUIRED
DTP Eligibility Start Date
REQUIRED
DTP Eligibility Start Date
REQUIRED
DTP Eligibility End Date
REF01 – Reference
Identification Qualifier
MI
MAID (WI Medicaid Recipient
ID)
MAID (WI Medicaid Recipient
ID)
HJ
Subscriber ID Card Number
Subscriber ID Card Number
SY
REF02 – Reference
Identification
Subscriber Social Security
Number
Subscriber Social Security
Number
NM103 – Subscriber Last
Name
NM104 – Subscriber First
Name
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DTP01 – Date/Time Qualifier
307
Eligibility Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
DTP03 – Eligibility Start Date
CCYYMMDD
Eligibility Start Date
Cannot be more than 1 year
prior to current date.
DTP01 – Date/Time Qualifier
307
Eligibility End Date
OPTIONAL
Page 257 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
DTP02 – Date/Time Period
Format Qualifier
RD8
Eligibility End Date Range
OPTIONAL
DTP Eligibility End Date
DTP03 – Eligibility End Date
CCYYMMDD CCYYMMDD
OPTIONAL
Loop 2110C
EQ - Service Type Code
Eligibility End Date
No future dates.
EQ01 - Service Type Code
30
DTP Eligibility End Date
SITUATIONAL
@Indicates that the field data may be obtained from the card swipe.
Page 258 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
Wyoming Medicaid
Search Options
Code
*1
*2
*3
*4
Search
Option
Subscriber
1
Subscriber
2
Subscriber
3
Subscriber
4
Field 1 Search
Field 2 Search
Field 4
Search
Field 3 Search
Subscriber Member ID
Subscriber SSN
Subscriber SSN
Subscriber DOB
Subscriber Last Name Subscriber First Name
Subscriber Last Name Subscriber First Name
Subscriber DOB
Subscriber
Gender
Payer Name
Payer Name
Wyoming Medicaid
Payer ID
WYMCD
Loop 2100A – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100A
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Entity
Identifier Code
REQUIRED
NM1 Information Source Name
REQUIRED
NM1 Information Source Name
REQUIRED
NM101 - Entity Identifier Code
PR
Payer
NM102 – Entity Type Qualifier
2
Non-Person Entity
NM108 - Identification Code
Qualifier
NM109 - Identification Code
PI
Payer Identification
WYMCD
Carrier ID
Loop 2100B – Eligibility Benefit Inquiry and Response
270/271 Health Care Eligibility Benefit Inquiry and Response
Segment
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100B
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Entity Identifier Code
REQUIRED
NM1 Information Receiver
Service Provider ID
SITUATIONAL
NM1 Information Receiver
Service Provider ID
NM101 - Entity Identifier code
1P
Provider
NM102 – Entity Type Qualifier
1
2
Person
Non-Person Entity
NM108 – Identification Code
Qualifier
SV
Medicaid Provider Number
NM109 – Identification Code
Medicaid Provider Number
SITUATIONAL
Page 259 of 259
Version 1.1
INGENIX Connectivity Solutions
1755 Telstar Drive, Suite 400
Colorado Springs, CO 80920
Tel: 719-277-7545 Fax: 719-277-0254
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
NM1 Information Receiver
Service Provider NPI
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
REF Information Receiver
Service Provider ID
SITUATIONAL
NM108 – Identification Code
Qualifier
XX
NM109 – Identification Code
REF01 – Identification Code
Qualifier
Service Provider NPI
Service Provider NPI
Q4
REF02 – Identification Code
Service Provider ID
Service Provider ID
Loop 2100C – Eligibility Benefit Inquiry and Response
Segment
270/271 Health Care Eligibility Benefit Inquiry and Response
This table includes only data elements requiring specific information for ICS processing.
Reference
Value
Definitions and Notes Specific
to ICS
Designator(s)
Loop 2100C
NM1 Subscriber Last Name
*3, *4
NM1 Subscriber First Name
*3, *4
NM Subscriber Member ID
*1
NM Subscriber Member ID
*1
REF Subscriber SSN
*2, *3
REF Subscriber SSN
*2, *3
DMG Subscriber Birth Date
NM103 – Subscriber Last
Name
Subscriber Last Name
Nm104 – Subscriber First
Name
Subscriber First Name
NM108 – Identification Code
Qualifier
MI
NM109 – Identification Code
REF01 – Reference
Identification Qualifier
Member Identification
Number
Member Identification
Number
SY
REF02 – Reference
Identification
Subscriber Social Security
Number
Subscriber Social Security
Number
DMG02 – Subscriber Birth
Date
CCYYMMDD
Subscriber Birth Date
DMG03 – Reference
Identification
F = Female
M = Male
Subscriber Gender
DTP01 – Date/Time Qualifier
307
Eligibility Start Date
DTP02 – Date/Time Period
Format Qualifier
D8
REQUIRED
DTP Eligibility Start Date
DTP03 – Eligibility Start Date
CCYYMMDD
REQUIRED
Loop 2110C
EQ - Service Type Code
EQ01 - Service Type Code
30
*2, *4
DMG Subscriber Gender
*4
DTP Eligibility Start Date
REQUIRED
DTP Eligibility Start Date
Eligibility Start Date
REQUIRED
Page 260 of 259
Version 1.1