GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Life & Annuity Insurance Company
HIPAA Transaction
Standard Companion Guide
Section 2 – 270/271
Refers to the
X12N Implementation Guide
004010X092A1
270/271 Health Care Eligibility/Benefit Inquiry and Response
GWL Companion Guide
Version 1.4
Revised
November 20, 2007
July 21, 2003 ● 004010X092A1.1.0
Page 1 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Disclosure Statement
The information provided here is for reference use only, and does not constitute the rendering of legal, financial, or
any other professional advice or recommendations by Great-West Life. Great-West Life makes no representation or
warranties of any kind in connection with the information provided herein, and hereby disclaims any other expressed
or implied warranties, including implied warranties of merchantability or fitness for a particular use or purpose.
Document Revision History
Version
1.0
1.1
Revision Date
07/21/2003
9/27/2005
1.1
1.2
9/27/2005
5/16/07
Description/Reference
Initial release.
Sections 2.6 and 3.2 - updated to include requirements for EB01 values 5 and 8
whenever EB01 = U or I. Implemented with Release 5.4 with BC upgrade 2.8.0.
See 271 EB01 Requirements document.
Published – Jan Murphy-Hole
Reviewed for changes to accommodate National Provider Identifier (NPI) and none
required.
1.3
10-05-07
Appendices deleted – placeholder and never created.
2.5.2.2 Request Date, page 11 - Added clarification to confirm that GWH only
returns current benefits but is able to return prior eligibility up to 18 months (tests
confirmed by Dennnis Ornelas):
1.4
11-20-07
2.5.2.2 Request Date, page 11 – added statement “If an eligibility request
comes in for a future date, we will quote the current effective date ”.
2003 Great-West Life & Annuity Insurance Company
All rights reserved. This document may be copied for Great-West Life internal use and for use by our Trading Partners.
Preface
This Companion Document to the ASC X12N Implementation Guides adopted under HIPAA clarifies and specifies
the data content when exchanging electronically with Great-West Life. Transmissions based on this companion
document, used in tandem with the X12N Implementation Guides, are compliant with both X12 syntax and those
guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N
Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information
that in any way exceeds the requirements or usage of data expressed in the Implementation Guides.
July 21, 2003 ● 004010X092A1.1.0
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GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Table of Contents
1 Introduction .............................................................................................................................. 4
2 General Information and Guidelines ....................................................................................... 4
2.1 Contact Information ......................................................................................................................................... 5
2.2 Disclaimer ......................................................................................................................................................... 5
2.3 Multiple Requests Per Transaction ................................................................................................................ 5
2.3.1 Real-time Requests .................................................................................................................................. 5
2.3.2 Batch Requests ........................................................................................................................................ 5
2.4 Dependent Request Submitted in the Subscriber Loop .............................................................................. 5
2.5 Search Options ................................................................................................................................................. 6
2.5.1 Member Match .......................................................................................................................................... 6
2.5.2 Eligibility/Benefit Match ............................................................................................................................. 6
2.5.2.1 Eligibility Service Type/Procedure................................................................................................... 6
2.5.2.2 Request Date .................................................................................................................................. 7
2.5.3 Search Segments/Elements ..................................................................................................................... 7
2.6 Eligibility/Benefit Response – Matched Member .......................................................................................... 8
2.7 Eligibility/Benefit Response AAA Error Responses ..................................................................................... 9
2.7.1 AAA Errors – Subscriber Level 2100C and Dependent Level 2100D ...................................................... 9
2.7.2 AAA Errors – Subscriber and Dependent Request Level 2110C and 2110D ........................................ 10
2.8 Active Coverage and Current Benefits ........................................................................................................ 10
2.9 Data Not Used ................................................................................................................................................. 10
2.9.1 270 Loops and Segments Not Used ....................................................................................................... 10
2.9.2 271 Loops and Segments Not Used ....................................................................................................... 11
3 Data Detail ............................................................................................................................... 13
3.1 Data Detail for 270 – Health Care Eligibility Benefit Inquiry ...................................................................... 13
3.2 Data Detail for 271 – Health Care Eligibility Benefit Response ................................................................. 20
July 21, 2003 ● 004010X092A1.1.0
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GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
1 Introduction
The 270/271 transactions are designed so that inquiry submitters (information receivers) can determine whether
an information source has a particular subscriber or dependent on file, and the health care eligibility and benefit
information about the subscriber or dependent. The 270/271 capabilities described in this guide can be utilized
by, but are not limited to, hospitals, professional providers, laboratories, and other payers.
The national transaction set implementation guide named in the HIPAA Administrative Simplification Electronic
Transaction rule is the primary source for definitions, data usage and requirements. This supplemental
document contains clarifications and Great-West Life specific requirements related to data usage and content
when submitting a HIPAA 270/271 transaction to Great-West Life.
This Companion Document is to assist those implementing the ASC X12N 270/271 – Health Care
Eligibility/Benefit Inquiry and Response transaction for use with Great-West Life. Great-West Life’s
recommendations are noted below; otherwise please refer to the ASC X12N Implementation Guide for
clarifications and data definitions.
The version of the ASC X12N 270/271 – Health Care Eligibility Benefit Inquiry and Response transaction is
004010X092A1 (includes October 2002 Addenda).
2 General Information and Guidelines
The sections below provide guidelines for the 270/271 – Health Care Eligibility/Benefit Inquiry and Response.
These sections provide the minimum data requirements for Great-West Life to correctly and completely process
this HIPAA transaction.
The purpose of generating a 270 is to obtain the eligibility and benefit information for a plan subscriber or
dependent. The information returned includes information such as whether the patient is enrolled in active
coverage for the requested date and also additional current benefit information when available. The member and
enrollment information is located in the GWL system based on a subset of the fields contained on the inbound
270 transaction. The member is identified primarily using the subscriber member ID number, patient date of
birth, patient first name and patient last name. (See section 2.5 for additional search option details.)
Great-West Life uses the 271 Health Care Eligibility Benefit Response to transmit the desired subscriber or
dependent eligibility and benefit information to the requester. There are a variety of types of responses that can
be received from this process. Great-West Life will return at least one EB (Eligibility or Benefit Information)
segment OR one AAA (Request Validation) segment in each 271 response transaction that has passed the
Interchange (Envelope) validation and Functional validation. If the transaction failed Interchange validation the
TA1 returned to the receiver will explain the error. If the transaction failed Functional validation the 997 returned
to the receiver will explain the error.
In all other cases, the processing will return a 271 response transaction. Based on the information submitted, the
response will contain 1 or more of the following:
 Active/Inactive/Non-covered Eligibility enrollment information
 Error responses to communicate if the member is located on the GWL systems or if the transaction needs to
be corrected and resubmitted for processing
 Benefit descriptions for the patient‘s plan when available.
July 21, 2003 ● 004010X092A1.1.0
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GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
The 270/271 transaction set can be submitted in Real Time or Batch mode. If the transaction set is submitted in
Real Time, the 270 transaction can be for a single patient only. If the transaction set is submitted in Batch, the
270 transaction can have up to 99 patient requests in a single transaction set (ST-SE loop). Please see section
2.3 for additional information.
2.1 Contact Information
Please see the Great West Life Standard Companion Guide - Section 1 for contact information.
2.2 Disclaimer
Enrollment information may change due to cancellations or other changes in coverage. Great West Life
acknowledges and understands that the information contained in the 271 response reflects current
enrollment data. Claims will be processed according to benefit and membership information on file at the
time of claim processing. Therefore, the information contained within a 271 response does not guarantee
reimbursement for services provided.
2.3 Multiple Requests Per Transaction
The 270 Health Care Eligibility Benefit Request can contain multiple Information Source (payer) loops,
Information Receiver (trading partner) loops and Service Provider loops per Transaction Set (ST-SE).
Great-West Life expects one Information Source loop that identifies Great-West Life as the intended payer
for the claim request and one Information Receiver loop that identifies the intended trading partner for the
claim response. However, if multiple loops are sent, Great-West Life will process all loops and return the
271 Health Care Eligibility Benefit Response for all loops received (Information Source/ Information
Receiver/ Provider).
Multiple requests can be submitted in both the real-time and batch transaction modes. However, there are
additional restrictions to the types of multiple requests that can be submitted real-time for performance
reasons.
2.3.1 Real-time Requests
Great West Life will receive and process no more than 1 patient request when submitting the
transaction in real-time mode. The single patient may be either a subscriber or dependent. The
patient may have up to 99 requests for eligibility information. Each occurrence of the 2110C loop
(Subscriber loop EQ segment) or 2110D loop (Dependent loop EQ segment) is a request.
2.3.2 Batch Requests
Great West Life will receive and process no more than 99 patient requests when submitting the
transaction in batch mode. The patient may be either a subscriber or dependent. As with real-time
each patient may have up to 99 requests for eligibility information? Each occurrence of the 2110C
loop (Subscriber loop EQ segment) or 2110D loop (Dependent loop EQ segment) is a request.
Multiple subscribers for one provider and/or multiple dependents for one subscriber can be
submitted. Requests for both the subscriber and that subscriber's dependent cannot be included in
the same subscriber loop. There must be one subscriber loop submitted for the request related to
the subscriber and a second subscriber loop submitted for the request related to the dependent.
2.4 Dependent Request Submitted in the Subscriber Loop
Great-West Life will search for the member submitted on the 270 inquiry as both a subscriber and
dependent regardless of where the member is submitted on the request. If the request is submitted with
the dependent information in the subscriber loop, Great West Life shall return the Eligibility/Benefit
Information in the dependent loop and return subscriber information found in the Great West Life eligibility
July 21, 2003 ● 004010X092A1.1.0
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GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
systems in the subscriber loop. (Future Release – Performing a successful match and returning the data in
the correct loop will be released in a future 2003 enhancement to the 270/271.)
2.5 Search Options
The 270 Health Care Eligibility Benefit Request includes parameters that allow Great-West Life to locate
the patient’s eligibility and benefits in our system. Eligibility is located in 2 distinct steps. First, the patient
and member are located (Member Match) and then the eligibility and benefit data are located for the
matched member/patient (Eligibility Match).
2.5.1 Member Match
Including the following four data elements on the incoming 270 will provide the greatest opportunity
to identify the patient:
 Member ID - required
 Patient date of birth
 Patient first name
 Patient last name
Great-West Life will attempt to identify a member if the Subscriber's Member ID and Patient's Date
of Birth is provided, or if the Subscriber's Member ID and patient's Last Name and Patient's First
Name is provided in the 270 inquiry.
If multiple possible matches are found using these four fields, we will continue to use additional
discriminators in an attempt to reduce a set of Multiple Patient Records found to One Patient
Record. These additional discriminators are:
 Patient group/plan number
 Patient gender
 Patient state
 Patient zip code
The group/plan number that will be used is taken from the REF segment in the patient loop. Great
West Life will use the REF02 field for the first segment encountered with a REF01 qualifier of '1L',
'IG', '18', or '6P'.
2.5.2 Eligibility/Benefit Match
Once a member is matched, Great-West Life searches to retrieve available eligibility and benefit
information based on the eligibility service type/procedure and date requested.
2.5.2.1 Eligibility Service Type/Procedure
The type of request is specified by either the EQ01 or EQ02 data element. GWL does not
explicitly process the EQ02 requests. If a 2110 loop exists with an EQ02 (instead of an
EQ01), then GWL processes the request as if the request was submitted with EQ01 = 30.
If a 2110 Loop exists with an EQ01, then this code value is mapped to the benefit types of
‘Medical’, ‘Dental’ or ‘Vision’ for determining the eligibility and benefit response. The
crosswalk for code mapping each valid EQ01 code value is contained in Appendix 1.
If GWL receives an EQ01 code value that is not appropriate for any of our plans, a no
coverage response is sent.
July 21, 2003 ● 004010X092A1.1.0
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270/271 – Health Care Eligibility/Benefit Inquiry and Response
GREAT-WEST LIFE COMPANION GUIDE Section 2
2.5.2.2 Request Date
The 270 transaction allows for the date of the request to be specified in multiple segments.
The request date can be specified in the Subscriber 2100C DTP Segment and/or
Subscriber Request 2110C DTP Segment when the Subscriber is the patient. The request
date can be specified in the Dependent 2100D DTP Segment and/or in the Dependent
Request 2110D DTP segment when the Dependent is the patient. In addition, no DTP
segments may be submitted at all (indicating the request is for the current date).
The dates specified in the DTP segments can be current, future or within the last 18 months
for eligibility requests. If an eligibility request is received for a future date, Great-West
Life will quote the current effective date. Great-West Life only returns current benefits in
the 271 response.
GWL determines the date used for each request as follows:
Patient
2110D
Dependent
Request
Date
DTP03
2110C
Subscriber
Request
Date
DTP03
2100D
Dependent
Date
2100C
Subscriber
Date
DTP03
DTP03
Request Date
to Use
Subscriber
N/A
Exists
N/A
Exists or Not
Exists
2110C DTP
Subscriber
N/A
Not Exists
N/A
Exists
2100C DTP
Subscriber
N/A
Not Exists
N/A
Not Exists
Processing Date
Dependent
Exists
N/A
Exists or Not
Exists
Exists or Not
Exists
2110D DTP
Dependent
Not Exists
N/A
Exists
Exists or Not
Exists
2100D DTP
Dependent
Not Exists
N/A
Not Exists
Exists
Processing Date
Dependent
Not Exists
N/A
Not Exists
Not Exists
Processing Date
2.5.3 Search Segments/Elements
Below are segments/elements that may be used by Great-West Life EDI system to correctly locate
the subscriber or dependent and return the appropriate eligibility/benefit response.
Page #
72
72
72
73
73
Loop
2100C
2100C
2100C
2100C
2100C
2100C
Segment
NM1
NM1
NM1
NM1
NM1
NM101
NM103
NM104
NM108
NM109
75
2100C
REF
REF01
76
78
2100C
2100C
REF
N4
REF02
N402
July 21, 2003 ● 004010X092A1.1.0
Element
Description
This loop will contain subscriber information.
This code will identify the entity as the subscriber.
This will be used as the subscriber's last name.
This will be used as the subscriber's first name.
This value must be 'MI'.
This must be the member identification number in order for a
patient to be found.
This will identify the type of reference number submitted in the
REF02 segment.
This will used as the subscriber's reference number.
This will be used as the state name for the subscriber.
Page 7 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
79
84
84
88
Loop
2100C
2100C
2100C
2100C
Segment
N4
DMG
DMG
DTP
Element
N403
DMG02
DMG03
DTP03
2110D
90
2110C
EQ
EQ01
96
2110C
EQ
EQ02
108
2110C
DTP
DTP03
NM101
NM103
NM104
NM108
NM109
2100D
114
115
115
2100D
2100D
2100D
115
115
2100D
2100D
NM1
NM1
NM1
NM1
NM1
116
2100D
REF
REF01
117
119
120
2100D
2100D
2100D
125
125
130
2100D
2100D
2100D
REF
N4
N4
DMG
DMG
DTP
REF02
N402
N403
DMG02
DMG03
DTP03
2110D
132
2110D
EQ
EQ01
137
2110D
EQ
EQ02
146
2110D
DTP
DTP03
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Description
The first 5 digits will be used as the zip code of the patient.
This will be used as the subscriber's date of birth.
This will be used as the subscriber's gender.
The date(s) submitted will be used to determine the eligibility
and benefit response when no date is submitted in the 2110C
loop.
This loop will contain subscriber eligibility and benefit
information.
This will determine whether medical, dental, or vision benefits
are returned.
Any value received in this segment will be considered a
request for medical benefits.
The dates submitted will be used to determine the eligibility
and benefit response. The dates submitted in this loop take
precedence over those submitted in the 2100C loop.
This loop will contain patient information when the patient is
not the subscriber
This code will be used to identify the entity as a dependent.
This will be used as the dependent's last name.
This will be used as the dependent's first name.
The value must be 'MI'.
This must be the member identification number in order for a
patient to be found.
This will identify the type of reference number submitted in the
REF02 segment.
This will used as the dependents reference number.
This will be used as the state name for the dependent.
The first 5 digits will be used as the zip code of the dependent.
This will be used as the dependent's date of birth.
This will be used as the dependent's gender.
The date(s) submitted will be used to determine the eligibility
and benefit response when no date is submitted in the 2110D
loop.
This loop will contain dependent eligibility and benefit
information.
This will determine whether we return medical, dental, or
vision benefits.
Any value received in this segment will be considered as a
request for medical benefits.
The dates submitted will be used to determine the eligibility
and benefit response. The dates submitted in this loop take
precedence over those submitted in the 2100D loop.
2.6 Eligibility/Benefit Response – Matched Member
For every EQ submitted in a 270 inquiry, with the exception of those circumstances listed in Error
Response Conditions listed in section 2.7, Great West Life will provide the following response when the
patient is found in our system:
July 21, 2003 ● 004010X092A1.1.0
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GREAT-WEST LIFE COMPANION GUIDE Section 2





270/271 – Health Care Eligibility/Benefit Inquiry and Response
Active or inactive status for the date of inquiry
The actual effective and termination date of coverage when available
When the member has active coverage on the date the inquiry is processed plan benefit information
will be returned when available
The contact phone number for additional eligibility/benefit questions
Additional GWL system information on the patient
Great West Life will categorize Service Type Codes as either medical, dental, or vision and provide a
detailed response based on benefit type, not an explicit response for each Service Type Code submitted.
See Appendices 1. The system will return active (’1’), inactive (‘6’), non-covered (‘I’) or Contact Following
Entity for Eligibility and Benefit Information (‘U’) in the 271 2110 EB eligibility response data field EB01.
The EB01 code of ‘U’ is returned in a small subset of special conditions based on the patient policy
number and in the case of Oral Surgery requests. In this case a contact phone number is supplied so that
the receiver can contact GWL for additional information. An additional EB01 code of “5” or “8 Active or
Inactive – Pending Investigation” will always be returned with an EB01 code of “U” or “I” . If there is a DTP
segment returned in the EB01 = “U” or “I” loop, the DTP segment will be duplicated in the EB01 = “5” or
“8” loop in order to tie the two loops together.
It may be necessary based on the GWL enrollment to respond with multiple EB segments for a date period
request. For example, if the request was for eligibility for 3/1/2003-6/30/2003 and the patient’s coverage on
GWL systems has a beginning effective date of 4/1/2003, multiple EB segments would be returned,
namely inactive coverage from 3/1/2003-3/31/2003 and active coverage from 4/1/2003-6/30/2003.
When benefit coverage dates are available they will be returned along with the EB segment denoted with
the coverage benefits (‘CB’) EB01 code.
When available, detail plan benefit information will be provided for members whenever the eligibility
response contains a variety of EB segments. These EB segments include EB01 codes of co-insurance
(‘A’), coverage benefits (‘CB’), deductible (‘C’), benefit description (‘D’), limitations (‘F’), and benefit
disclaimer (‘P’). See appendix 2 for detailed message segments returned which further describe benefit
data.
For patients with active coverage, a phone number will be included in the PER segment in the 2100A
Information Source loop. This phone number can be used to contact the payer for additional information.
For a matched patient, additional data will be added or corrected in the 271 response if not already
supplied on the input. This includes patient address information (N3 and N4 segments), patient date of
birth, patient gender, group/plan number, and patient names as they exist on the GWL system.
2.7 Eligibility/Benefit Response AAA Error Responses
Great-West Life will return a Request Validation (AAA) if a patient is not conclusively matched in the GWL
proprietary systems at the 2100C subscriber level or 2100D dependent level. In addition, Request
Validation (AAA) errors can be returned at the 2110C and 2110D level in a matched member response.
2.7.1 AAA Errors – Subscriber Level 2100C and Dependent Level 2100D
If the subscriber patient is not conclusively matched one or more of the following errors will be
generated at the 2100C subscriber level. The same list of error codes can be generated for the
Dependent at the 2100D dependent level.
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270/271 – Health Care Eligibility/Benefit Inquiry and Response
GREAT-WEST LIFE COMPANION GUIDE Section 2
Reject Reason Code
42
58
60
64
65
66
67
68
Description
Unable to respond at current time
Invalid/Missing Date of Birth
Date of Birth Follows Date of Service
Invalid/Missing Patient ID
Invalid/Missing Patient Name
Invalid/Missing Patient Gender Code
Patient Not Found
Duplicate Patient ID Number
2.7.2 AAA Errors – Subscriber and Dependent Request Level 2110C and 2110D
If the patient is matched one or both of the following errors may still be returned in the AAA loop at
the 2110 level.
Reject Reason Code
Description
60
Date of Birth Follows Date of Service
62
Date of Service Not Within Allowable Inquiry Period
2.8 Active Coverage and Current Benefits
Active Coverage
"Active" is defined as coverage where the effective date is less than or equal to the date of service and the
cancel date is null, greater than, or equal to the date of service. "Inactive" is the period where the cancel
date is less than or equal to the date of service.
Current Benefits
A patient is identified as having “Current Benefits” if they are actively enrolled in a plan product which had
a beginning effective date on or before the system processing date and the product coverage is not
termed, or the term date is greater than the current date.
2.9 Data Not Used
2.9.1 270 Loops and Segments Not Used
Below are entire loops not used by the Great West Life Eligibility/ Benefit systems at this time:
Loop
2000A
2100A
2000B
Usage
R
R
S
Name
Information Source Level
Information Source Name
Information Receiver Level
Notes/Comments
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Below are segments, within loops, not used by the Great West Life Eligibility/ Benefit systems at this
time:
Loop
2100B
Segment
REF
Usage
S
2100B
2100B
N3
N4
S
S
July 21, 2003 ● 004010X092A1.1.0
Name
Information Receiver
Additional Identification
Information Receiver Address
Information Receiver
Notes/Comments
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
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270/271 – Health Care Eligibility/Benefit Inquiry and Response
GREAT-WEST LIFE COMPANION GUIDE Section 2
Loop
Segment
Usage
2100B
PER
S
2100B
PRV
S
2100C
2100C
2100C
2110C
PRV
N3
INS
AMT
S
S
2110C
III
S
2110C
REF
S
2100D
2100D
2100D
2110D
PRV
N3
INS
AMT
S
S
2110D
III
S
2110D
REF
S
S
S
Name
City/State/Zip Code
Information Receiver Contact
Information
Information Receiver Provider
Information
Provider Information
Subscriber Address
Subscriber Relationship
Subscriber Spend Down
Amount
Subscriber Eligibility or
Benefit Inquiry Information
Subscriber Additional
Information
Provider Information
Dependent Address
Dependent Relationship
Dependent Spend Down
Amount
Dependent Eligibility or
Benefit Inquiry Information
Dependent Additional
Information
Notes/Comments
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
Not used by GWL at this time.
2.9.2 271 Loops and Segments Not Used
All loops are used by the 271 outbound transaction.
Below are segments, within loops, not used by the Great West Life Eligibility/Benefit systems at this
time:
Loop
2000A
2100A
Segment
AAA
REF
Usage
S
S
2100B
REF
S
2100B
2100B
N3
N4
S
S
2100B
PER
S
2100B
PRV
S
2110C
REF
S
2120C
N3
S
2120C
N4
S
July 21, 2003 ● 004010X092A1.1.0
Name
Request Validation
Information Source Additional
Identification
Information Receiver
Additional Identification
Information Receiver Address
Information Receiver
City/State/Zip Code
Information Receiver Contact
Information
Information Receiver Provider
Information
Subscriber Additional
Information
Subscriber Benefit Related
Entity Address
Subscriber Benefit Related
Notes/Comments
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
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GREAT-WEST LIFE COMPANION GUIDE Section 2
Loop
Segment
Usage
2120C
PER
S
2120C
PRV
S
2110D
REF
S
2120D
N3
S
2120D
N4
S
2120D
PER
S
2120D
PRV
S
July 21, 2003 ● 004010X092A1.1.0
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Name
City/State/Zip Code
Subscriber Benefit Related
Contact Information
Subscriber Benefit Related
Provider Information
Dependent Additional
Information
Dependent Benefit Related
Entity Address
Dependent Benefit Related
City/State/Zip Code
Dependent Benefit Related
Contact Information
Dependent Benefit Related
Provider Information
Notes/Comments
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Not used by GWL at this time
Page 12 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
3 Data Detail
This section provides the data detail information for the 270/271 – Health Care Eligibility Benefit Inquiry and Response transaction. The tables
below contain the minimum data requirements that must be followed for Great-West Life to process the 270/270 Health Care Eligibility Benefit
Inquiry transaction.
Data loops segments and elements will ONLY be included if Great-West Life needs to provide clarification on how the data item is used in our
processing. This clarification can:
 Limit the repeat of loops, or segments
 Limit the length of a simple data element
 Specify a sub-set of the Implementation Guide internal code listings used
 Clarify the use of loops, segments, composite, and simple data elements
 Any other information tied directly to a loop, segment, composite, or simple data element pertinent to trading electronically with GreatWest Life
 Define specific data element contents.
3.1 Data Detail for 270 – Health Care Eligibility Benefit Inquiry
This section contains specific loops, segments, and content detail that must be included in the 270 Health Care Eligibility Benefit Inquiry
transaction. Please read them carefully.
Page #
36
36
Loop
ST
Name
ST
ST01
BHT
38
38
39
BHT
BHT
BHT01
BHT02
39
BHT
BHT04
41
2000A
41
2000A
HL
July 21, 2003 ● 004010X092A1.1.0
Description
Transaction Set Header
Transaction Set Identifier
Code
Beginning of Hierarchical
Transaction
Hierarchical Structure Code
Transaction Set Purpose
Code
Transaction Set Creation
Date
Information Source Level
Information Source Level
Codes
Length
270
4/9
0022
13
4/4
2/2
8/8
Notes/Comments
Use to identify a Eligibility, Coverage or Benefit
inquiry transaction set
Use to assign the transaction set load date. This
should be the date this transaction set was created.
Great-West Life does not validate or use any of
the data in the Information Source loop. Only one
loop should be sent identifying Great-West Life as
payer, however, GWL will process all loops
received.
This segment is required and will occur once per
ST/SE segment.
Page 13 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
42
Loop
2000A
Name
HL01
Description
Hierarchical ID number
42
43
2000A
2000A
HL03
HL04
Hierarchical Level Code
Hierarchical Child Code
44
2100A
44
2100A
NM1
Information Source Name
44
2100A
NM101
45
2100A
45
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Codes
Length
1/12
20
1
1/2
1/1
Entity ID code
2B
2/3
NM102
Entity Type Qualifier
2
1/1
2100A
NM103
2100A
NM108
GreatWest Life
46
1/35
46
Name Last or Organization
Name
Identification Code Qualifier
46
2100A
NM109
Identification Code
80705
2/80
48
2000B
48
2000B
HL
Hierarchical Level
48
2000B
HL01
Hierarchical ID Number
1/12
48
2000B
HL02
1/12
48
2000B
HL03
Hierarchical Parent Id
Number
Hierarchical Level Code
21
1/2
49
2000B
HL04
Hierarchical Child Code
1
1/1
50
2100B
NM1
Information Receiver Name
Information Source Name
1/3
Information Receiver Level
July 21, 2003 ● 004010X092A1.1.0
Notes/Comments
Use to uniquely identify the HL segment. Start at 1
incrementing by 1 for each HL within the ST-SE
transaction set.
Use to identify this level as the Information Source.
Use value '1' since there will always be additional
subordinate HL data segments.
Great-West Life does not validate or use any of
the data in the Information Source loop. Only one
loop should be sent identifying Great-West Life as
payer, however, GWL will process all loops
received.
This segment is required and will occur once per
ST/SE segment
Use to identify Great West Life as a Third Party
Administrator.
Use to identify Great West Life as a non-person
entity.
Organization Name. We will not validate at this level.
Indicates that the code submitted in NM109 is our
ETIN number.
This value is the Great-West Life electronic
transmitter identification number.
Great-West Life does not validate any of the data
in the Information Receiver loop. Only one loop
should be sent identifying the approved GreatWest Life Trading Partner, however, GWL will
process all loops received
This segment is situational and may occur once per
ST/SE segment.
Use to uniquely identify the HL segment. Start at 1
incrementing by 1 for each HL within the ST-SE
transaction set.
Use the value from loop 2000A, segment HL01.
Use to identify this as the Information Receiver
hierarchy level.
Use value '1' since there will always be additional
subordinate HL data segments.
This segment is required and will occur once per
ST/SE segment.
Page 14 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Page #
50
Loop
2100B
Name
NM101
Description
Entity ID Code
Codes
Length
2/3
51
2100B
NM102
Entity Type Qualifier
1/1
51
2100B
NM103
1/35
51
2100B
NM104
Name Last/Organization
Name
Name First
52
2100B
NM108
Identification Code Qualifier
1/2
52
2100B
NM109
Identification Code
2/80
66
2000C
1/25
Subscriber Level
67
2000C
HL
Hierarchical Level
67
2000C
HL01
Hierarchical ID Number
68
68
68
2000C
2000C
2000C
HL02
HL03
HL04
Hierarchical Patient Number
Hierarchical Level Code
Hierarchical Child Code
69
2000C
TRN
Subscriber Trace Number
69
70
2000C
2000C
TRN01
TRN02
Trace Type Code
Reference Identification
70
2000C
TRN03
70
2000C
TRN04
Originating Company
Identifier
Reference Identification
July 21, 2003 ● 004010X092A1.1.0
1/12
22
0, 1
1
1/12
1/2
1/1
1/2
1/30
10/10
1/30
Notes/Comments
Great West Life will return the value submitted in the
271 response.
Great West Life will return the value submitted in the
271 response.
Great West Life will return the value submitted in the
271 response.
Great West Life will return the value submitted in the
271 response.
Great West Life will return the value submitted in the
271 response.
Great West Life will return the value submitted in the
271 response.
This loop should be submitted for each request to
identify whether the subscriber or dependent is
the patient. In real time processing the subscriber
level will occur once per ST/SE transaction set
pairing since requests are related to a single
patient.
However, for batch processing multiple
subscriber levels could be included in the ST/SE
transaction set. A subscriber level will be
included for each subscriber patient request and
subscriber identified for dependent requests.
This segment will occur once for each subscriber
level.
Use to uniquely identify the HL segment. Start at 1
incrementing by 1 for each HL within the ST-SE
transaction set.
Use the value from loop 2000B, HL01 segment.
Use to identify this as the subscriber hierarchy level.
Use to identify whether the Subscriber has a
subordinate level.
This segment is situational and may occur twice per
subscriber level.
Great West Life will return the value submitted in the
271 response.
Great West Life will return the value submitted in the
271 response.
Great West Life will return the value submitted in the
271 response.
Page 15 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Name
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Page #
71
Loop
2100C
71
2100C
NM1
Subscriber Name
71
2100C
NM101
Entity ID Code
IL
2/3
72
72
2100C
2100C
NM102
NM103
Entity Type Qualifier
Name Last
1/1
1/35
72
2100C
NM104
Name First
1/25
Identifies the entity as a person.
73
2100C
NM108
Identification Code Qualifier
1
Subscriber
Last
Name
Subscriber
First
Name
MI
Notes/Comments
This loop is required to occur once for each
occurrence of 2000C loop.
This segment is situational and will occur once for
each subscriber level.
Identifies that subscriber information will be submitted
in this loop.
Identifies the entity as a person.
Used to identify the member.
1/2
73
2100C
NM109
Identification Code
74
2100C
REF
75
2100C
REF01
76
2100C
REF02
Subscriber Additional
Identification
Reference Identification
Qualifier
Reference Identification
78
2100C
N4
Subscriber Address
79
2100C
N402
State or Province Code
2/2
Use ‘MI’ for Member Identification Number. If ‘MI” is
not used, then the subscriber will not be found.
The 9 digit member identification number from the
member’s identification card (ID Card). Do not include
spaces, dashes and other special characters that may
appear on the ID card. This is 9 digits ONLY.
This segment is situational and may occur up to 9
times per subscriber level.
While additional REF01 values may be submitted,
only these 4 are utilized by GWL.
Great West Life will use only the first occurrence of
the group/plan identification number when
REF01=‘1L’, ‘IG’, ‘18’ or ‘6P’ to help identify the
member.
This segment is situational and may occur once per
subscriber level.
Data must pass external code set validation.
79
2100C
N403
Postal Code
3/15
Data must pass external code set validation.
83
2100C
DMG
84
2100C
DMG01
D8
2/3
84
2100C
DMG02
Subscriber Demographic
Information
Date Time Period Format
Qualifier
Date Time Period
Member's
date of
birth
1/35
This segment is situational and may occur once per
subscriber level.
Use to identify the format of the date in DMG02 as
CCYYMMDD.
Used to identify the member.
July 21, 2003 ● 004010X092A1.1.0
Description
Subscriber Information
Codes
Length
2/80
1L, IG, 18,
6P
2/3
1/30
Code Set
22
Code Set
51
Page 16 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
84
Loop
2100C
Name
DMG03
Description
Gender Code
87
2100C
DTP
Subscriber Date
88
2100C
DTP01
88
2100C
DTP02
88
2100C
89
2110C
90
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Codes
F, M, U
Length
1/1
Date/Time Qualifier
102, 307,
435, 472
3/3
D8/RD8
2/3
DTP03
Date/Time Period Format
Qualifier
Date Time Period
2110C
EQ
Subscriber Eligibility or
Benefit Information
Eligibility or Benefit Inquiry
90
2110C
EQ01
Service Type Code
1/2
95
2110C
EQ02
2/2
106
2110C
DTP
Composite Medical
Procedure Identifier
Subscriber Eligibility/Benefit
Date
106
2110C
DTP01
Date/Time Qualifier
102, 307,
435, 472
3/3
107
2110C
DTP02
Date/Time Period Format
Qualifier
D8/RD8
2/3
July 21, 2003 ● 004010X092A1.1.0
1/35
Notes/Comments
Use to identify the subscriber gender code. Great
West Life may use this as a discriminator to reduce a
set of Multiple Patient Records found to One Patient
Record.
This segment is situational and may be used when
the subscriber is the patient. Use this segment when
a single set of dates apply to all information requests
(EQ segments) for the subscriber patient. Otherwise
eligibility request date should be submitted in the
2110C DTP loop. (Note: GWL will ignore the segment
if submitted with the ‘102’ Date/Time Qualifier field in
this loop)
Although Great West Life will accept any Date/Time
Qualifier we will always return a value of '307' in the
271 response.
Indicates whether the date in DTP03 is a single date
(D8) or a range of dates (RD8).
Date format for a single date is CCYYMMDD. Date
format for a range of dates is CCYYMMDDCCYYMMDD.
This loop is required when the patient is the
subscriber.
This segment is required when the subscriber is the
patient and may occur up to 99 times.
Great West Life will use to determine whether we will
respond with detailed medical, dental or vision
benefits; or an EB01='U', or an EB01='I' .
Great West Life will treat any value sent in EQ02 as if
a Service Type Code (EQ01) of '30' was received.
This segment is situational and may be submitted
once for each 2110C EB Segment to reflect the date
of the request when the subscriber is the patient. Use
this segment when a single set of dates do not apply
to all information requests (EQ segments) for the
subscriber patient.
Although Great West Life will accept any Date/Time
Qualifier we will always return a value of '307' in the
271 response.
Indicates whether the date in DTP03 is a single date
(D8) or a range of dates (RD8).
Page 17 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Name
DTP03
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Page #
107
Loop
2110C
Description
Date Time Period
Codes
Length
1/35
108
2000D
110
2000D
HL
Hierarchical Level
110
2000D
HL01
Hierarchical ID Number
110
111
111
112
2000D
2000D
2000D
2000D
HL02
HL03
HL04
TRN
Hierarchical Patient Number
Hierarchical Level Code
Hierarchical Child Code
Dependent Trace Number
112
113
2000D
2000D
TRN01
TRN02
Trace Type Code
Reference Identification
113
2000D
TRN03
113
2000D
TRN04
Originating Company
Identifier
Reference Identification
114
2100D
114
2100D
NM1
Dependent Name
114
2100D
NM101
Entity ID Code
03
2/3
115
115
2100D
2100D
NM102
NM103
Entity Type Qualifier
Name Last
1/1
1/35
115
2100D
NM104
Name First
1
Dependen
t Last
Name
Dependen
t First
Name
Great West Life will return the value submitted in the
271 response.
Great West Life will return the value submitted in the
271 response.
Great West Life will return the value submitted in the
271 response.
This loop is required to occur once for each
occurrence of 2000D loop.
This segment is required when the patient is a
dependent and will occur once.
Identifies that dependent information will be submitted
in this loop.
Identifies the entity as a person.
Used to identify the dependent.
1/25
Identifies the entity as a person.
Dependent Level
1/12
23
0
1
1/12
1/2
1/1
1/2
1/30
10/10
1/30
Dependent Information
July 21, 2003 ● 004010X092A1.1.0
Notes/Comments
Date format for a single date is CCYYMMDD. Date
format for a range of dates is CCYYMMDDCCYYMMDD. Dates submitted at the 2110C loop
take precedence over dates submitted in the 2100C
loop.
This loop is required when the patient is a
dependent. In real time processing, the ST/SE
transaction set is limited to a single occurrence of
this dependent level. In batch mode, this segment
may occur multiple times to denote different
dependents for a subscriber.
This segment is situational and will occur once for
each dependent level.
Use to uniquely identify the HL segment. Start at 1
incrementing by 1 for each HL within the ST-SE
transaction set.
Use the value from subscriber loop 2000C HL01.
Use to identify this as the Dependent hierarchy level.
Use to identify that there is no subordinate level.
This segment is situational and may occur twice per
dependent level.
Page 18 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
116
2100D
REF
116
2100D
REF01
117
2100D
REF02
Dependent Additional
Identification
Reference Identification
Qualifier
Reference Identification
119
2100D
N4
Dependent Address
120
2100D
N402
State or Province Code
120
2100D
N403
Postal Code
124
2100D
DMG
125
2100D
DMG01
125
2100D
DMG02
Dependent Demographic
Information
Date Time Period Format
Qualifier
Date Time Period
125
2100D
DMG03
Gender Code
129
2100D
DTP
Dependent Date
130
2100D
DTP01
130
2100D
DTP02
130
131
2100D
2110D
DTP03
July 21, 2003 ● 004010X092A1.1.0
270/271 – Health Care Eligibility/Benefit Inquiry and Response
2/2
This segment is situational and may occur up to 9
times per dependent.
While additional REF01 values may be submitted,
only these 4 are utilized.
Great West Life will use only the first occurrence of
the group/plan identification number when
REF01=‘1L’, ‘IG’, ‘18’ or ‘6P’ to help identify the
member.
This segment is situational and may occur once per
dependent when the patient is a dependent.
Data must pass external code set validation.
3/15
Data must pass external code set validation.
D8
2/3
Patient's
date of
birth
F, M, U
1/35
This segment is situational and may occur once per
dependent when the dependent is the patient.
Use to identify the format of the date in DMG02 as
CCYYMMDD.
Used to identify the patient.
Date/Time Qualifier
102, 307,
435, 472
3/3
Date/Time Period Format
Qualifier
Date Time Period
Dependent Eligibility or
Benefit Information
D8/RD8
2/3
1L, IG, 18,
6P
2/3
1/30
Code Set
22
Code Set
51
1/1
Use to identify the dependent gender code. Great
West Life may use this as a discriminator to reduce a
set of Multiple Patient Records found to One Patient
Record.
This segment is situational and may be used when
the dependent is the patient. Use this segment when
a single set of dates applies to all information
requests (EQ segments) for the dependent patient.
Otherwise eligibility request date should be submitted
in the 2110D DTP loop. (Note: GWL will ignore DTP
segment if Date/Time Qualifier has the value ‘102’ in
this loop)
Although Great West Life will accept any Date/Time
Qualifier we will always return a value of '307' in the
271 response.
1/35
This loop is required when the patient is the
dependent.
Page 19 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
131
2110D
EQ
Eligibility or Benefit Inquiry
132
2110D
EQ01
Service Type Code
1/2
137
2110D
EQ02
2/2
145
2110D
DTP
Composite Medical
Procedure Identifier
Dependent Eligibility/Benefit
Date
145
2110D
DTP01
Date/Time Qualifier
102, 307,
435, 472
3/3
146
2110D
DTP02
D8/RD8
2/3
146
2110D
DTP03
Date/Time Period Format
Qualifier
Date Time Period
1/35
This segment is required when the dependent is the
patient and may occur up to 99 times.
Great West Life will use to determine whether we will
respond with detailed medical, dental or vision
benefits; or an EB01='U', or an EB01='I'.
Great West Life will treat any value sent in EQ02 as a
Service Type Code (EQ01) of '30'.
This segment is situational and may be submitted
once for each 2110D EB Segment to reflect the date
of the request when the dependent is the patient. Use
this segment when a single set of dates does not
apply to all information requests (EQ segments) for
the dependent patient.
Although Great West Life will accept any Date/Time
Qualifier we will always return a value of '307' in the
271 response.
Indicates whether the date in DTP03 is a single date
(D8) or a range of dates (RD8).
Date format for a single date is CCYYMMDD. Date
format for a range of dates is CCYYMMDDCCYYMMDD.
3.2 Data Detail for 271 – Health Care Eligibility Benefit Response
This section contains specific loops, segments, and content detail that may be included in the 271 Health Care Eligibility Benefit
Response transaction. Please read them carefully.
Page #
154
154
Loop
ST
156
156
157
157
BHT
BHT
BHT
158
2000A
158
2000A
Name
ST
ST01
Description
Transaction Set Header
Transaction Set Identifier Code
BHT
Beginning of Hierarchical
Transaction
Hierarchical Structure Code
Transaction Set Purpose Code
Transaction Set Creation Date
BHT01
BHT02
BHT04
Information Source Level
HL
July 21, 2003 ● 004010X092A1.1.0
Information Source Level
Codes
Length
270
4/9
0022
11
4/4
2/2
8/8
Notes/Comments
Use to identify a Eligibility, Coverage or Benefit
inquiry transaction set
Use to assign the transaction set load date. This
should be the date this transaction set was created.
This loop is required and will occur once per
ST/SE segment.
This segment is required and will occur once per
ST/SE segment.
Page 20 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
159
Loop
2000A
Name
HL01
Description
Hierarchical ID number
159
159
2000A
2000A
HL03
HL04
Hierarchical Level Code
Hierarchical Child Code
163
2100A
163
2100A
NM1
Information Source Name
163
2100A
NM101
164
2100A
164
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Codes
Length
1/12
20
0 or 1
1/2
1/1
Entity ID code
2B
2/3
NM102
Entity Type Qualifier
2
1/1
2100A
NM103
2100A
NM108
GreatWest Life
46
1/35
165
Name Last or Organization
Name
Identification Code Qualifier
165
2100A
NM109
Identification Code
80705
2/80
168
2100A
PER
169
2100A
PER01
Information Source Contact
Name
Contact Function Code
IC
2/2
169
2100A
PER03
TE
2/2
170
2100A
PER04
Communication Number
Qualifier
Communication Number
172
2100A
AAA
Request Validation
173
2100A
AAA01
Yes/No Condition or Response
Code
Y/N
1/1
173
2100A
AAA03
Reject Reason Code
04, 41, 42
2/2
Information Source Name
1/3
1/80
Notes/Comments
Use to uniquely identify the HL segment. Start at 1
incrementing by 1 for each HL within the ST-SE
transaction set.
Use to identify this level as the Information Source.
Value will be '0' when no subordinate HL
segments. Value will be '1' when there are
additional subordinate HL data segments.
This loop is required and will occur once per
ST/SE segment.
This segment is required and will occur once per
ST/SE segment. No validations will be done on the
Information Source data.
Use to identify Great West Life as a Third Party
Administrator.
Use to identify Great West Life as a non-person
entity.
Organization Name
Indicates that the code submitted in NM109 is our
ETIN number.
This value is the Great-West Life electronic
transmitter identification number.
This segment is situational and will be returned
once per ST/SE segment.
This identifies the value in PER04 as a contact
phone number.
This identifies the value in PER04 as a telephone
number.
When available Great West Life will return a
contact phone number in the 271 response in
AAABBBCCCC format in the 271 response.
This segment is situational and may occur up to 3
times per ST/SE segment.
Great West Life will return a value of 'N' when
AAA03 = '41' or '42', or will return a value of 'Y'
when AAA03 = ''04'.
Great West Life will return:
* '04' when more than 99 transactions are received
in batch mode or more than 1 transaction is
received in real time mode
July 21, 2003 ● 004010X092A1.1.0
Page 21 of 37
270/271 – Health Care Eligibility/Benefit Inquiry and Response
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
174
Loop
2100A
Name
AAA04
Description
Follow Up Action Code
Codes
C, N, Y, R
Length
1/1
Notes/Comments
* '41' when the entity identified in GS02 is not
authorized to submit a 270 inquiry to the entity
identified in ISA08 or GS03
* '42' when Great West Life systems are
unavailable
Great West Life will return:
* 'C' when AAA03 = '04'
* 'N' when AAA03= '41'
* 'Y' when AAA03 = '42' and the transaction is
processed in batch mode
175
2000B
Information Receiver Level
175
2000B
HL
Hierarchical Level
176
2000B
HL01
Hierarchical ID Number
176
176
2000B
2000B
HL02
HL03
Hierarchical Parent Id Number
Hierarchical Level Code
21
1/12
1/2
177
2000B
HL04
Hierarchical Child Code
0, 1
1/1
178
2100B
178
2100B
NM1
Information Receiver Name
178
2100B
NM101
Entity ID Code
2/3
179
2100B
NM102
Entity Type Qualifier
1/1
179
2100B
NM103
Name Last/Organization Name
1/35
179
2100B
NM104
Name First
1/25
1/12
Information Receiver Name
July 21, 2003 ● 004010X092A1.1.0
* 'R' when AAA03 = '42' and the transaction is
processed in real-time mode.
This loop is situational and may occur once per
ST/SE segment.
This segment is situational and may occur once per
ST/SE segment.
Use to uniquely identify the HL segment. Start at 1
incrementing by 1 for each HL within the ST-SE
transaction set.
Use the value from loop 2000A, segment HL01.
Use to identify this as the Information Receiver
hierarchy level.
Use to identify whether the Information Receiver
has a subordinate level.
This loop is required and will occur once for
each occurrence of 2000B loop.
This segment is required and will occur once per
ST/SE segment. No validations will be done on the
Information Receiver data.
Great West Life will return the value submitted in
the 270 inquiry.
Great West Life will return the value submitted in
the 270 inquiry.
Great West Life will return the value submitted in
the 270 inquiry.
Great West Life will return the value submitted in
the 270 inquiry.
Page 22 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Page #
180
Loop
2100B
Name
NM108
Description
Identification Code Qualifier
Codes
Length
1/2
181
2100B
NM109
Identification Code
184
2100B
AAA
185
185
2100B
2100B
AAA01
AAA03
Information Receiver Request
Validation
Yes/No Condition or Response
Reject Reason Code
186
187
2100B
2000C
AAA04
Follow Up Action Code
Subscriber Level
187
2000C
HL
Hierarchical Level
188
2000C
HL01
Hierarchical ID Number
188
189
2000C
2000C
HL02
HL03
Hierarchical Patient Number
Hierarchical Level Code
22
1/12
1/2
189
2000C
HL04
Hierarchical Child Code
0, 1
1/1
190
2000C
TRN
Subscriber Trace Number
191
2000C
TRN01
Trace Type Code
2
1/2
191
2000C
TRN02
Reference Identification
1/30
192
2000C
TRN03
Originating Company Identifier
10/10
192
2000C
TRN04
Reference Identification
1/30
193
2100C
193
2100C
NM1
Subscriber Name
193
2100C
NM101
Entity ID Code
IL
2/3
194
2100C
NM102
Entity Type Qualifier
1
1/1
2/80
N
41
1/1
2/2
N
1/1
1/12
Subscriber Information
July 21, 2003 ● 004010X092A1.1.0
Notes/Comments
Great West Life will return the value submitted in
the 270 inquiry.
Great West Life will return the value submitted in
the 270 inquiry.
This segment is situational and may occur once per
St/SE segment.
Will be returned when the request is not valid.
Great West Life will return this AAA segment when
there are Authorization/Access Restrictions.
Resubmission not allowed.
This loop is situational and may occur once per
ST/SE segment.
This segment is situational and will occur once per
ST/SE segment.
Use to uniquely identify the HL segment. Start at 1
incrementing by 1 for each HL within the ST-SE
transaction set.
Use the value from loop 2000B, HL01 segment.
Use to identify this as the subscriber hierarchy
level.
Use to identify whether the Subscriber has a
subordinate level.
This segment is situational and may occur twice
per ST/SE segment.
There may be up to 2 TRN segments on the 270.
Great West Life will return both.
Great West Life will return the value submitted in
the 270 inquiry.
Great West Life will return the value submitted in
the 270 inquiry.
Great West Life will return the value submitted in
the 270 inquiry.
This loop is required to occur once for each
occurrence of 2000C loop.
This segment is required and will occur once per
ST/SE segment.
Identifies that subscriber information will be
submitted in this loop.
Identifies the entity as a person.
Page 23 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
194
Loop
2100C
Name
NM103
Description
Name Last
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Codes
Subscriber
Last
Name
Length
1/35
Notes/Comments
*Great West Life will return the last name submitted
on the 270 inquiry if the last name is not found in
GWL systems or the system is unavailable.
*Great West Life will return the last name found in
GWL systems if different than the last name
submitted on the 270 inquiry, or if the last name is
not received on the 270.
194
2100C
NM104
Name First
Subscriber
First
Name
1/25
*Great West Life will return nothing if the last name
is not received on the 270 inquiry and the member
is not matched in GWL systems.
*Great West Life will return the first name
submitted on the 270 inquiry if the first name is not
found in GWL systems or the system is
unavailable.
*Great West Life will return the first name found in
GWL systems if different than the first name
submitted on the 270 inquiry, or if the first name is
not received on the 270.
195
2100C
NM108
Identification Code Qualifier
195
2100C
NM109
Identification Code
196
2100C
REF
197
2100C
REF01
Subscriber Additional
Identification
Reference Identification
Qualifier
198
2100C
REF02
Reference Identification
200
2100C
N3
Subscriber Address
July 21, 2003 ● 004010X092A1.1.0
MI
1/101/2
2/80
18, 6P, EJ
2/3
1/30
*Great West Life will return nothing if the first name
is not received on the 270 inquiry and the member
is not matched in GWL systems.
Use to identify the value in NM109 as the GreatWest Life subscriber identification number.
Great West Life will return the value submitted in
the 270 inquiry.
This segment is situational and may occur once per
ST/SE segment.
Great West Life will return 'EJ' when found on the
270 inquiry. REF01 will contain an '18'(plan
number) or '6P' (group number) if that data is
included in the 271 REF02 response
Great West Life will return the 270 value when
REF01 = 'EJ', or will return the plan number found
in GWL systems when REF01 = '18' or the group
number when REF01 = '6P'.
This segment is situational and may occur once per
ST/SE segment.
Page 24 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Page #
200
Loop
2100C
Name
N301
Description
Address Information
201
2100C
N4
Subscriber City/State/Zip Code
201
2100C
N401
City Name
202
2100C
N402
State or Province Code
202
2100C
N403
Postal Code
207
2100C
AAA
Subscriber Request Validation
207
2100C
AAA01
Yes/No Condition or Response
Codes
Length
1/55
2/30
Code Set
22
Code Set
51
2/2
Y, N
1/1
3/15
Notes/Comments
Great West Life will return the street address found
in GWL systems when valid data is found,
otherwise this segment will not be returned.
This segment is situational and may occur once per
ST/SE segment.
Great West Life will return the city name found in
GWL systems when valid data is found, otherwise
this segment will not be returned.
Data must pass external code set validation. Great
West Life will return state if found in GWL systems.
Data must pass external code set validation. Great
West Life will return zip code if found in GWL
systems.
This segment is situational and may occur up to 9
times per ST/SE segment.
Great West Life will return a value of 'Y' when
 GWL systems are unavailable
 patient is not found
 duplicate members are found
Great West Life will return a value of 'N' when:
 patient is not found
 date of birth and/or member ID is not
received on the 270
 date of birth in GWL system is after the
date submitted in the DTP segment.
July 21, 2003 ● 004010X092A1.1.0
Page 25 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
208
Loop
2100C
Name
AAA03
Description
Reject Reason Code
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Codes
42, 58, 60,
64, 65, 66,
67, 68
Length
2/2
Notes/Comments
The following values may be returned:
* '42' - When system is unavailable
* '58' - When date of birth is not received on the
270 inquiry
* '60' - When date of birth is after the date of inquiry
* '64' - When member ID is missing on the 270
inquiry
* '65' - When member's last name is missing on the
270 received and we are unable to identify the
member
* '66' - When gender code is missing or invalid on
the 270 received and we are unable to identify the
member
* '67' - When we are unable to identify the member
* '68' - When duplicate members are found
209
2100C
AAA04
Follow Up Action Code
C, R, Y
1/1
*Great West Life will return a value of 'C' when
AAA03 = 58 or 60 or 64 or 65 or 66 or 67 or 68.
*Great West Life will return a value of 'R' when
AAA03 = 42 and the transaction is submitted in
batch mode.
210
2100C
DMG
D8
DMG02
Subscriber Demographic
Information
Date Time Period Format
Qualifier
Date Time Period
211
2100C
DMG01
211
2100C
211
2100C
DMG03
Gender Code
F, M, U
July 21, 2003 ● 004010X092A1.1.0
2/3
1/35
1/1
*Great West Life will return a value of 'Y' when
AAA03 = 42 and the transaction is submitted in
real-time mode.
This segment is situational and may occur once per
ST/SE segment when the subscriber is the patient.
Use to identify the format of the date in DMG02 as
CCYYMMDD.
Use to identify the subscriber birth date in
CCYYMMDD format (D8 qualifier).
Use to identify the subscriber gender code.
Page 26 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Page #
212
Loop
2100C
Name
INS
Description
Subscriber Relationship
Codes
Length
213
2100C
INS01
Yes/No Condition or Response
Y
1/1
213
213
2100C
2100C
INS02
INS03
Individual Relationship Code
Maintenance Type Code
18
001
2/2
3/3
214
2100C
INS04
Maintenance Reason Code
25
2/3
216
216
217
2100C
2100C
2100C
DTP
DTP01
DTP02
307
D8/RD8
3/3
2/3
217
2100C
DTP03
Subscriber Date
Date/Time Qualifier
Date/Time Period Format
Qualifier
Date Time Period
219
2110C
219
2110C
EB
Eligibility or Benefit Information
219
2110C
EB01
Eligibility or Benefit Information
221
226
2110C
2110C
EB03
EB04
Service Type Code
Insurance Type Code
228
2110C
EB05
Plan Coverage Description
228
2110C
EB06
Time Period Qualifier
1/35
Subscriber Eligibility or
Benefit Information
July 21, 2003 ● 004010X092A1.1.0
U, I, 1, 5,
6, 8, B, D,
CB, C, A,
F, P
PR, PS,
HM, IN
Notes/Comments
This segment is situational and will occur once per
ST/SE segment when identifying information
returned in the 271 response is different than
received on the 270 inquiry.
Great West Life will always return a 'Y' as the
insured will always be the subscriber.
Indicates relationship is 'self'.
Great West Life will return this value indicating
identifying elements returned in the 271 response
are different than those submitted in the 270
inquiry.
Great West Life will return this value indicating
identifying elements returned in the 271 response
are different than those submitted in the 270
inquiry.
This segment is situational.
Great West Life will always respond with '307'.
Indicates whether the date in DTP03 is a single
date (D8) or a range of dates (RD8).
Date format for a single date is CCYYMMDD. Date
format for a range of dates is CCYYMMDDCCYYMMDD.
This loop is required when the patient is the
subscriber and a AAA segment is not returned
at the 2100A, 2100B or 2100C loop.
This segment is required when the subscriber is
the patient. There is no limit to the number of
repeats of the EB segment. When benefits are
returned there will be multiple occurrences of this
segment.
1/2
1/2
1/3
See Appendices 1.
Used to identify the member's type of insurance.
1/50
Used to return Provider Network information for
medical plans, and used to identify plan type for
dental plans.
7, 22, 23,
24, 36, 37
Page 27 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Page #
229
Loop
2110C
Name
EB07
Description
Monetary Amount
229
2110C
EB08
Percent
229
230
230
2110C
2110C
2110C
EB09
EB10
EB11
Quantity Qualifier
Quantity
Yes/No Condition Response
DY
Y, N
2/2
1/15
1/1
230
233
2110C
2110C
EB12
HSD
Yes/No Condition Response
Health Care Services Delivery
Y, N
1/1
235
235
240
2110C
2110C
2110C
HSD05
HSD06
DTP
Time Period Qualifier
Number of Periods
Subscriber Eligibility/Benefit
Date
24, 34
24
1/2
1/3
240
2110C
DTP01
Date Time Qualifier
292,307
3/3
241
2110C
DTP02
Date Time Period Format
Qualifier
D8, RD8
2/3
241
242
2110C
2110C
DTP03
AAA
Date Time Period
Subscriber Request Validation
242
2110C
AAA01
July 21, 2003 ● 004010X092A1.1.0
Codes
Length
1/18
1/10
Notes/Comments
Used to identify copay, deductible, year to date
paid amounts, and maximums (EB01 = 'B' or 'C' or
'D'). Value will be returned with no decimal point.
Used to identify coinsurance percent (EB01=A).
Value will be returned with no decimal point
Used to indicate whether there are pre-certification
requirements.
Used to indicate In or Out of Network benefits.
This segment is situational and may occur up to 9
times per EB loop when the subscriber is the
patient.
Used to define period.
Used to indicate the number of periods.
This segment is situational and may be returned up
to 20 times per EB loop when the subscriber is the
patient.
Great West Life will return a value of '292' with the
actual effective and termination date returned in
DTP03 if at least one active eligibility response is
returned. If the member was inactive during the
entire period of the inquiry effective and termination
dates will not be returned. We will return a value of
'307' to respond explicitly to the dates received in
the 270 inquiry or to the date of processing if no
dates are received in the 270.
Use to identify the date format of DTP03 as
CCYYMMDD for a single date or CCYYMMDDCCYYMMDD for a range of dates.
1/35
1/1
This segment is situational and may occur once per
EB loop.
Great West Life will return a value of 'Y' when the
date submitted in the 270 inquiry is greater than 18
months prior to the date of processing. We will
return a value of 'N' when the date of birth received
in the 270 is after the date of inquiry.
Page 28 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
243
Loop
2110C
Name
AAA03
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Description
Reject Reason Code
Codes
60, 62
Length
2/2
Notes/Comments
Great West Life may return the following values:
* '60' - When date of birth is after the date of inquiry
* '62' - When date submitted in the 270 inquiry is
greater than 18 months prior to the date of
processing
243
244
2110C
2110C
AAA04
MSG
Follow Up Action Code
Message Text
244
2110C
MSG01
Free Form Message Text
246
2115C
246
2115C
III
Subscriber Eligibility or
Benefit Additional Information
Information
247
248
249
2115C
2115C
2120C
III01
III02
249
2120C
LS
249
250
2120C
2120C
LS01
NM1
250
251
251
2120C
2120C
2120C
NM101
NM102
NM103
252
252
252
2120C
2120C
2120C
NM104
NM105
NM108
July 21, 2003 ● 004010X092A1.1.0
Code List Qualifier
Industry Code
Subscriber Benefit Related
Entity Name
Subscriber Eligibility or Benefit
Information
Loop Identifier Code
Subscriber Benefit Related
Entity Name
Entity Identifier Code
Entity Type Qualifier
Name Last or Organization
Name
Name First
Name Middle
Identification Code Qualifier
C
1/1
1/264
ZZ
22, 23, 99
1/3
1/30
This segment is situational and may occur up to 10
times per EB loop when the subscriber is the
patient.
Great West Life will return several MSG segments
to further clarify benefits. These messages will vary
by benefit type and plan type.
This loop is situational and may occur multiple
times per ST/SE segment.
This segment is situational and may occur up to 10
times per EB loop when the subscriber is the
patient
Code Source 237
This loop is situational and will only be
returned once per ST/SE segment when the
member's plan type is HMO or POS (EB04 = HM
or PS)
Used to identify beginning of the Subscriber Benefit
Related Entity Name loop.
2120
1/6
This segment is situational and may occur once per
ST/SE segment.
P3
1
34, 51,
SV, XX
2/3
1/1
1/35
1/25
1/25
1/2
Use to identify the last name of the PCP.
Use to identify the first name of the PCP
Use to identify the middle name/initial of the PCP
Use to identify the type of identification code being
submitted in NM109. Great West Life will return the
value received in the 270 if 34 or 51 or SV or XX,
otherwise will return nothing.
Page 29 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
253
Loop
2120C
Name
NM109
Description
Identification Code
264
265
2120C
2000D
LE01
Loop Trailer
Dependent Level
265
2000D
HL
Dependent Level
266
2000D
HL01
Hierarchical ID Number
266
266
2000D
2000D
HL02
HL03
Hierarchical Patient Number
Hierarchical Level Code
267
268
2000D
2000D
HL04
HL
269
2000D
269
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Codes
2120
Length
2/80
Notes/Comments
Great West Life will return the value received in the
270 if NM108 = 34 or 51 or SV or XX, otherwise
will return nothing.
1/6
1/12
23
1/12
1/2
Hierarchical Child Code
Dependent Trace Number
0
1/1
TRN01
Trace Type Code
2
1/2
2000D
TRN02
Reference Identification
1/30
270
2000D
TRN03
Originating Company Identifier
10/10
270
2000D
TRN04
Reference Identification
1/40
271
2100D
271
2100D
NM1
Dependent Name
271
2100D
NM101
Entity ID Code
03
2/3
272
272
2100D
2100D
NM102
NM103
Entity Type Qualifier
Name Last
1
Patient
Last
Name
1/1
1/35
Dependent Name
This loop is situational and will occur once per
ST/SE segment when the patient is a
dependent. Dependent eligibility and benefit
information will be returned in the dependent
loop regardless of which loop it is received in
the 270 inquiry.
This segment is situational and will occur once per
ST/SE segment when the patient is a dependent
Use to uniquely identify the HL segment. Start at 1
incrementing by 1 for each HL within the ST-SE
transaction set.
Use the value from loop 2000C HL01 segment.
Use to identify this as the Dependent hierarchy
level.
Use to identify that there is no subordinate level.
This segment is situational and may occur twice
per ST/SE segment.
There may be up to 2 TRN segments on the 270.
Great West Life will return both.
Great West Life will return the value submitted in
the 270 inquiry.
Great West Life will return the value submitted in
the 270 inquiry if equal to '2', otherwise will return
nothing.
Great West Life will return the value submitted in
the 270 inquiry.
This loop is required to occur once for each
occurrence of 2000D loop.
This segment is required when the patient is a
dependent and will occur once per ST/SE segment.
Identifies that dependent information will be
submitted in this loop.
Identifies the entity as a person.
*Great West Life will return the last name submitted
on the 270 inquiry if the last name is not found in
GWL systems or the system is unavailable.
*Great West Life will return the last name found in
July 21, 2003 ● 004010X092A1.1.0
Page 30 of 37
270/271 – Health Care Eligibility/Benefit Inquiry and Response
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
272
Loop
2100D
Name
NM104
Description
Name First
273
2100D
NM108
Identification Code Qualifier
273
2100D
NM109
Identification Code
274
2100D
REF
275
2100D
REF01
Dependent Additional
Identification
Reference Identification
Qualifier
276
2100D
REF02
Reference Identification
277
2100D
N3
Dependent Address
277
2100D
N301
Address Information
278
2100D
N4
Dependent City/State/Zip Code
278
2100D
N401
City Name
279
2100D
N402
State or Province Code
July 21, 2003 ● 004010X092A1.1.0
Codes
Patient
First
Name
MI
Length
1/25
1/2
2/80
18, 6P, EJ
2/3
1/30
1/55
2/30
Code Set
22
2/2
Notes/Comments
GWL systems if different than the last name
submitted on the 270 inquiry, or if the last name is
not received on the 270.
*Great West Life will return nothing if the last name
is not received on the 270 inquiry and the member
is not matched in GWL systems.
*Great West Life will return the first name
submitted on the 270 inquiry if the first name is not
found in GWL systems or the system is
unavailable.
*Great West Life will return the first name found in
GWL systems if different than the first name
submitted on the 270 inquiry, or if the first name
was not received on the 270.
Use to identify the value in NM109 as the GreatWest Life member identification number.
Great West Life will return the value submitted in
the 270 inquiry.
This segment is situational and may occur once per
ST/SE segment when the patient is a dependent.
Great West Life will return 'EJ' when found on the
270 inquiry. REF01 will contain an '18'(plan
number) or '6P' (group number) if that data is
included in the 271 REF02 response
Great West Life will return the 270 value when
REF01 = 'EJ' , or will return the plan number found
in GWL systems when REF01 = '18' or the group
number when REF01 = '6P'.
This segment is situational and may occur once per
ST/SE segment when the patient is a dependent.
Great West Life will return the street address found
in GWL systems when valid data is found,
otherwise this segment will not be returned.
This segment is situational and may occur once per
ST/SE segment when the patient is a dependent
Great West Life will return the city name found in
GWL systems when valid data is found, otherwise
this segment will not be returned.
Data must pass external code set validation.
Page 31 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Page #
279
Loop
2100D
Name
N403
Description
Postal Code
284
2100D
AAA
Dependent Request Validation
284
2100D
AAA01
Yes/No Condition or Response
285
2100D
AAA03
Reject Reason Code
Codes
Code Set
51
Y, N
42, 58, 60,
64, 65, 66,
67, 68
Length
3/15
Notes/Comments
Data must pass external code set validation.
1/1
This segment is situational and may occur up to 9
times per ST/SE segment when the patient is a
dependent.
Great West Life will return a value of 'Y' when
 GWL systems are unavailable
 patient is not found
 duplicate members are found
2/2
Great West Life will return a value of 'N' when:
 patient is not found
 date of birth and/or member ID is not
received on the 270
 date of birth in GWL system is after the
date submitted in the DTP segment.
The following values may be returned:
* '42' - When system is unavailable
* '58' - When date of birth is not received on the
270 inquiry
* '60' - When date of birth is after the date of inquiry
* '64' - When member ID is missing on the 270
inquiry
* '65' - When member's last name is missing on the
270 received and we are unable to identify the
patient
* '66' - When gender code is missing or invalid on
the 270 received and we are unable to identify the
member
* '67' - When we are unable to identify the member
* '68' - When duplicate members are found
July 21, 2003 ● 004010X092A1.1.0
Page 32 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
286
Loop
2100D
Name
AAA04
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Description
Follow Up Action Code
Codes
C, R, Y
Length
1/1
Notes/Comments
*Great West Life will return a value of 'C' when
AAA03 = 58 or 60 or 64 or 65 or 66 or 67 or 68.
*Great West Life will return a value of 'R' when
AAA03 = 42 and the transaction is submitted in
batch mode.
287
2100D
DMG
288
2100D
DMG01
288
2100D
DMG02
Dependent Demographic
Information
Date Time Period Format
Qualifier
Date Time Period
288
289
2100D
2100D
DMG03
INS
Gender Code
Dependent Relationship
F, M, U
1/1
290
290
2100D
2100D
INS01
INS02
Yes/No Condition or Response
Individual Relationship Code
1/1
2/2
290
2100D
INS03
Maintenance Type Code
N
01, 19, 21,
34
001
291
2100D
INS04
Maintenance Reason Code
25
2/3
293
2100D
DTP
Dependent Date
July 21, 2003 ● 004010X092A1.1.0
D8
2/3
1/35
3/3
*Great West Life will return a value of 'Y' when
AAA03 = 42 and the transaction is submitted in
real-time mode.
This segment is situational and may occur once per
ST/SE segment when the patient is a dependent.
Use to identify the format of the date in DMG02 as
CCYYMMDD.
Use to identify the dependent birth date in
CCYYMMDD format (D8 qualifier).
Use to identify the dependent gender code.
This segment is situational and will occur once per
ST/SE segment when identifying information
returned in the 271 response is different than
received on the 270 inquiry.
Use to identify the patient as a dependent.
Great West Life will return this value indicating
identifying elements returned in the 271 response
are different than those submitted in the 270
inquiry.
Great West Life will return this value indicating
identifying elements returned in the 271 response
are different than those submitted in the 270
inquiry.
This segment is situational. When dates are
submitted at both the Dependent level and the
Eligibility/Inquiry level, the dates at the
Eligibility/Inquiry level will take precedence.
Page 33 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Page #
293
Loop
2100D
Name
DTP01
Description
Date/Time Qualifier
Codes
307
Length
3/3
294
2100D
DTP02
Date/Time Period Format
Qualifier
D8/RD8
2/3
294
295
2100D
2110D
DTP03
Date Time Period
Dependent Eligibility or
Benefit Information
295
2110D
EB
Eligibility or Benefit Information
296
2110D
EB01
Eligibility or Benefit Information
298
2110D
EB03
Service Type Code
303
2110D
EB04
Insurance Type Code
305
2110D
EB05
Plan Coverage Description
305
2110D
EB06
Time Period Qualifier
305
2110D
EB07
Monetary Amount
July 21, 2003 ● 004010X092A1.1.0
Notes/Comments
Great West Life will always return this value as
'307'. When dates are submitted at both the
Dependent level and the Eligibility/Inquiry level, the
dates at the Eligibility/Inquiry level will take
precedence. If the DTP segment is submitted only
at the 2100D level, it will be returned at the 2110D
level.
Use to identify the date format as CCYYMMDD for
a single date or CCYYMMDD-CCYYMMDD for a
range of dates.
1/35
This loop is required when the patient is a
dependent and a AAA segment is not returned
at the 2100A, 2100B or 2100D loop. There is no
limit to the number of repeats of the EB loop.
This segment is required when the dependent is
the patient. There is no limit to the number of
repeats of the EB segment. When benefits are
returned there will be multiple occurrences of this
segment.
U, I, 1, 5,
6, 8, B, D,
CB, C, A,
F, P
1, 2, 24,
26, 30, 32,
35, 38, 48,
53, 55,
98,AI, AJ,
AL, A7,
A8, EQ01
value
PR, PS,
HM, IN
7, 22, 23,
24, 36, 37
1/2
1/2
See Appendices 1.
1/3
Used to identify the type of insurance.
1/50
Used to return Provider Network information for
medical plans, and used to identify plan type for
dental plans.
1/2
1/18
Used to identify copay, deductible, year to date
paid amounts, and maximums (EB01 = 'B' or 'C' or
'D'). Value will be returned with no decimal point.
Page 34 of 37
270/271 – Health Care Eligibility/Benefit Inquiry and Response
GREAT-WEST LIFE COMPANION GUIDE Section 2
Page #
306
Loop
2110D
Name
EB08
Percent
Description
Codes
Length
1/10
306
306
307
2110D
2110D
2110D
EB09
EB10
EB11
Quantity Qualifier
Quantity
Yes/No Condition Response
DY
Y, N
2/2
1/15
1/1
307
309
2110D
2110D
EB12
HSD
Yes/No Condition Response
Health Care Services Delivery
Y, N
1/1
311
311
316
2110D
2110D
2110D
HSD05
HSD06
DTP
Time Period Qualifier
Number of Periods
Dependent Eligibility/Benefit
Date
24, 34
24
1/2
1/3
316
2110D
DTP01
Date Time Qualifier
292,307
3/3
317
2110D
DTP02
Date Time Period Format
Qualifier
D8, RD8
2/3
317
318
2110D
2110D
DTP03
AAA
Date Time Period
Dependent Request Validation
318
2110D
AAA01
319
2110D
AAA03
Used to indicate whether there are pre-certification
requirements.
Used to indicate In or Out of Network benefits.
This segment is situational and may occur up to 9
times per EB loop when the patient is a dependent.
Used to define period.
Used to indicate the number of periods.
This segment is situational and may be returned up
to 20 times per EB loop when the patient is a
dependent.
Great West Life will return a value of '292' with the
actual effective and termination date returned in
DTP03 if at least one active eligibility response is
returned. If the member was inactive during the
entire period of the inquiry effective and termination
dates will not be returned. We will return a value of
'307' to respond explicitly to the dates received in
the 270 inquiry or to the date of processing if no
dates received in the 270. No DTP Segment will be
returned when the value of EB01='U'.
Use to identify the date format for DTP03as
CCYYMMDD for a single date or CCYYMMDDCCYYMMDD for a range of dates.
1/35
1/1
Reject Reason Code
Notes/Comments
Used to identify coinsurance percent (EB01=A).
Value will be returned with no decimal point
60, 62
2/2
This segment is situational and may occur once per
EB loop when the patient is a dependent
Great West Life will return a value of 'Y' when the
date submitted in the 270 inquiry is greater than 18
months prior to the date of processing. We will
return a value of 'N' when the date of birth received
in the 270 is after the date of inquiry.
Great West Life may return the following values:
* '60' - When date of birth is after the date of inquiry
* '62' - When date submitted in the 270 inquiry is
greater than 18 months prior to the date of
processing
July 21, 2003 ● 004010X092A1.1.0
Page 35 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Page #
319
320
Loop
2110D
2110D
Name
AAA04
MSG
Description
Follow Up Action Code
Message Text
320
2110D
MSG01
Free Form Message Text
322
2115D
322
2115D
III
Dependent Eligibility or
Benefit Additional Information
Information
323
2115D
III01
Code List Qualifier
324
325
2115D
2120D
III02
Industry Code
Dependent Benefit Related
Entity Name
325
2120D
LS
325
326
2120D
2120D
LS01
NM1
326
327
327
2120D
2120D
2120D
NM101
NM102
NM103
328
328
328
2120D
2120D
2120D
NM104
NM105
NM108
Dependent Eligibility or Benefit
Information
Loop Identifier Code
Dependent Benefit Related
Entity Name
Entity Identifier Code
Entity Type Qualifier
Name Last or Organization
Name
Name First
Name Middle
Identification Code Qualifier
329
2120D
NM109
Identification Code
340
2120D
LE01
Loop Trailer
July 21, 2003 ● 004010X092A1.1.0
Codes
C
Length
1/1
1/264
ZZ-Code
Source
237
22, 23, 99
Notes/Comments
This segment is situational and may occur up to 10
times per EB loop when the dependent is the
patient.
Great West Life will return several MSG segments
to further clarify benefits. These messages will vary
by benefit type and plan type. See appendix 2.
This loop is situational and may occur multiple
times per ST/SE segment.
This segment is situational and may occur up to 10
times per EB loop when the patient is a dependent
1/3
1/30
This loop is situational and will only be
returned once per ST/SE segment when the
patient's plan type is HMO or POS (EB04 = HM
or PS)
Used to identify beginning of the Dependent
Benefit Related Entity Name loop.
2120
1/6
This segment is situational and may occur once per
ST/SE segment when the patient is a dependent.
P3
1
34, 51,
SV, XX
2/3
1/1
1/35
1/25
1/25
1/2
2/80
2120
Use to identify the last name of the PCP.
Use to identify the first name of the PCP
Use to identify the middle name/initial of the PCP
Use to identify the type of identification code being
submitted in NM109. Great West Life will return the
value received in the 270 if 34 or 51 or SV or XX,
otherwise will return nothing.
Great West Life will return the value received in the
270 if NM108 = 34 or 51 or SV or XX, otherwise
will return nothing.
1/6
Page 36 of 37
GREAT-WEST LIFE COMPANION GUIDE Section 2
270/271 – Health Care Eligibility/Benefit Inquiry and Response
Legend:
Column
Page #
Loop
Name
Description
Codes
Length
Notes/Comments
Description
The page in the ASC X12 Implementation Guide that the loop/segment/element can be found on.
The Loop Reference for the loop/segment/element
The name for the data item. The name of a loop is the first segment within the loop.
Element, segment, or loop descriptive name.
A list of the sub-set of codes that are used for this data element. If any HIPAA defined code is acceptable then leave
the column blank. This column is ONLY used if Great-West Life specifies a subset.
The length of the data element in the Great-West Life operational data. This can be less than the HIPAA defined length
but NOT greater.
Describes the Great-West Life data content of the data item.
July 21, 2003 ● 004010X092A1.1.0
Page 37 of 37