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 Page 2 of 37 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 Page 3 of 37 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 Page 4 of 37 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 Page 5 of 37 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 Page 6 of 37 270/271 – 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 Page 8 of 37 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. July 21, 2003 ● 004010X092A1.1.0 Page 9 of 37 270/271 – 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. Page 10 of 37 270/271 – 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 Page 11 of 37 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