Eligibility (270/271) Dental Payers Companion Guide

Eligibility (270/271)
Dental Payers Companion Guide

Refers to the Implementation Guides
Based on ASC X12N version: 005010X279A1
April 3, 2014
Companion Guide Version 1.1
Disclosure Statement
Exchange EDI is committed to maintaining the integrity and security of health care data in accordance with applicable
laws and regulations.
This document is intended only as a supplement to and not a replacement for the ASC Guide as mandated under the
Health Insurance Portability and Accountability Act (HIPAA). If you do not have the full HIPAA implementation guide,
you can download it from the Washington Publishing Company (WPC) internet website at http://www.wpc-edi.com/.
2013 Exchange EDI, LLC.

All rights reserved.
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Preface
Companion Guides (CG) may contain two types of data, instructions for electronic communications with the publishing
entity (Communications/Connectivity Instructions) and supplemental information for creating transactions for the
publishing entity while ensuring compliance with the associated ASC X12 IG (Transaction Instructions). Either the
Communications/Connectivity component or the Transaction Instruction component must be included in every CG. The
components may be published as separate documents or as a single document.
The Communications/Connectivity component is included in the CG when the publishing entity wants to convey the
information needed to commence and maintain communication exchange.
The Transaction Instruction component is included in the CG when the publishing entity wants to clarify the IG
instructions for submission of specific electronic transactions. The Transaction Instruction component content is limited
by ASCX12s copyrights and Fair Use statement.
CORE Preface:
This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA
clarifies and specifies the data content when exchanging electronically with Exchange EDI. Transmissions based on this
companion guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC 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 usages of data expressed in the Implementation Guides.
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Table of Contents
INTRODUCTION .................................................................................................................................................................. 7
Scope ................................................................................................................................................................................................. 7
Overview ........................................................................................................................................................................................... 7
References ......................................................................................................................................................................................... 7
Additional Information ...................................................................................................................................................................... 8
GETTING STARTED WITH EXCHANGE EDI ...................................................................................................................... 9

Working with Exchange EDI ............................................................................................................................................................ 9
Certification and Testing Overview .................................................................................................................................................. 9
CONNECTIVITY WITH THE PAYER .................................................................................................................................. 10

Process Flow ................................................................................................................................................................................... 10
Transmission Administrative Procedures ........................................................................................................................................ 11
Re-Transmission Procedure ............................................................................................................................................................ 12
Communication Protocol Specifications ......................................................................................................................................... 12
Passwords ........................................................................................................................................................................................ 15
CONTACT INFORMATION ................................................................................................................................................ 16

Exchange EDI Insurance Eligibility Support .................................................................................................................................. 16
Exchange EDI Enrollment and Customer Support .......................................................................................................................... 16
Applicable Websites........................................................................................................................................................................ 16
CONTROL SEGMENTS AND ENVELOPES ......................................................................................................................... 17

Interchange Information .................................................................................................................................................................. 17
ISA-IEA .......................................................................................................................................................................................... 17
GS-GE ............................................................................................................................................................................................. 18
ST-SE .............................................................................................................................................................................................. 18
PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ................................................................................................. 19

Search Options ................................................................................................................................................................................ 19
Data Usage ...................................................................................................................................................................................... 19
ACKNOWLEDGEMENTS.................................................................................................................................................... 20
TRANSACTION SPECIFIC INFORMATION ........................................................................................................................ 20
Aetna 10004 ................................................................................................................................................................................. 21
AFLAC Dental 10398 .................................................................................................................................................................. 24
Alan Sturm and Associates - Dental - 10798 .................................................................................................................................. 26
Altus Dental - 10786 ....................................................................................................................................................................... 27
BCBS of Alabama 10025 ............................................................................................................................................................. 28
BCBS of Alabama (Institutional) 10609 ...................................................................................................................................... 30
BCBS of Arizona 10027 .............................................................................................................................................................. 32
BCBS of Arkansas 10028 ............................................................................................................................................................ 34
BCBS of Central New York 10461 .............................................................................................................................................. 36
BCBS of Colorado (Wellpoint Anthem) 10029 ........................................................................................................................... 38
BCBS of Connecticut (Wellpoint Anthem) 10030 ....................................................................................................................... 40
BCBS of Georgia 10032 .............................................................................................................................................................. 42
BCBS of Indiana (Wellpoint Anthem) 10258 .............................................................................................................................. 44
BCBS of Kansas 10034 ................................................................................................................................................................ 46
BCBS of Kansas City 10473 ........................................................................................................................................................ 48
BCBS of Kentucky (Wellpoint Anthem) 10259 .......................................................................................................................... 50
BCBS of Maine (Wellpoint Anthem) 10036 ................................................................................................................................ 52
BCBS of Michigan (Institutional) 10519 ..................................................................................................................................... 54
BCBS of Michigan (Professional) 10038 ..................................................................................................................................... 56
BCBS of Missouri (Wellpoint Anthem) 10322 ............................................................................................................................ 58
BCBS of Nevada (Wellpoint Anthem) 10260 .............................................................................................................................. 60
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BCBS of New Hampshire (Wellpoint Anthem) 10261 ................................................................................................................ 62

BCBS of New York (Empire) 10043 ........................................................................................................................................... 64
BCBS of New York (Excellus) 10323 ......................................................................................................................................... 66
BCBS of North Carolina 10383 ................................................................................................................................................... 68
BCBS of Ohio (Wellpoint Anthem) 10044 .................................................................................................................................. 70
BCBS of South Carolina 10047 ................................................................................................................................................... 72
BCBS of the Rochester Area (NY) 10469 ................................................................................................................................... 74
BCBS of Utica-Watertown (NY) 10470 ...................................................................................................................................... 76
BCBS of Virginia (Wellpoint Anthem) 10049 ............................................................................................................................. 78
BCBS of Wisconsin (Wellpoint Anthem) 10299 ......................................................................................................................... 80
Blue Benefit Administrators of Mass 10803 ................................................................................................................................ 82
Blue Cross of California 10051 .................................................................................................................................................... 84
Brokers National - Dental - 10783 .................................................................................................................................................. 86
Care Improvement Plus 10806 ..................................................................................................................................................... 87
CIGNA/Great West Healthcare 10062 ......................................................................................................................................... 90
DeCare Dental Health Insurance - 10780........................................................................................................................................ 93
Delta Dental .................................................................................................................................................................................... 94
Dental Benefit Providers - 10787 .................................................................................................................................................... 96
Employee Benefit Services - Dental - 10784 .................................................................................................................................. 97
Evercare 10807............................................................................................................................................................................. 98
Flex Compensation - Dental - 10799 ............................................................................................................................................ 101
Florida Combined Life - Dental - 10811 ....................................................................................................................................... 102
Group Health Cooperative of South Central Wisconsin - Dental - 10781 .................................................................................... 103
Guardian Life Insurance Co. of America - Dental - 10788 ........................................................................................................... 104
Hawaii Medical Assurance Association - Dental - 10785 ............................................................................................................. 105
HealthPlan of Nevada 10804...................................................................................................................................................... 106
Healthsource Provident - Dental - 10789 ...................................................................................................................................... 109
Hershey Healthsmile - Dental - 10795 .......................................................................................................................................... 110
MetLife Dental - 10134 ................................................................................................................................................................. 111
Patriot Dental - 10782 ................................................................................................................................................................... 112
Provident Preferred Network - Dental - 10790 ............................................................................................................................. 113
Securian Dental - 10792 ................................................................................................................................................................ 114
Securian/Patriot Dental - 10793 .................................................................................................................................................... 115
TennDent - 10794 ......................................................................................................................................................................... 116
UNICARE - Dental - 10791 .......................................................................................................................................................... 117
United Healthcare 10002 ............................................................................................................................................................ 118
United Concordia Companies, Inc. - Dental - 10810 .................................................................................................................... 121
United Concordia Federal Employees Program - Dental - 10809 ................................................................................................. 122
Wilson McShane - Dental - 10797 ................................................................................................................................................ 123
Zenith Administrators (MN) - Dental - 10796 .............................................................................................................................. 124
APPENDIX A: SPECIAL ENROLLMENT PAYERS............................................................................................................ 125

APPENDIX B: PAYER MAINTENANCE SCHEDULE ........................................................................................................ 126
APPENDIX C: TRANSACTION EXAMPLES ..................................................................................................................... 130
APPENDIX D: CHANGE SUMMARY ................................................................................................................................ 158
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Introduction
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires Exchange EDI to comply with the
electronic data interchange (EDI) standards for health care as established by the Secretary of Health and Human Services
(HHS). The ANSI X12N implementation guides have been established as the standards of compliance for electronic
health care transactions.
Scope
This Companion Guide (CG) is intended for use by Exchange EDI partners as a supplement to the standards set forth in
the ANSI X12N implementation guides. This Companion Guide assumes compliance with all loops, segments and data
elements contained in the 005010X279A1 implementation guide. This Companion Guide only includes the loops,
segments, and data elements that require further clarification beyond the information defined in the 005010X279A1
implementation guide.
Overview
Exchange EDI has compiled this document to expand upon the requirements set forth in the ANSI X12N 005010X279A1
implementation guide.
This CG contains the following topics
Data formats, content, codes, business rules, and characteristics of the electronic transaction
Technical requirements and transmission options
Information on testing procedures that each trading partner is recommended to complete prior to transmitting
electronic transactions
Payer-specific enrollment and downtime information
This document should be used in conjunction with the ANSI X12N 005010X279A1 Implementation Guide throughout the
process of submitting transactions through Exchange EDI to each supported payer.
References
Exchange EDI supports the ANSI X12N 5010A1 270/271. The full implementation guide, published by the Washington
Publishing Company, can be obtained at www.wpc-edi.com.
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Additional Information
System Maintenance Schedule
System maintenance, when scheduled, will occur during the following time frame.
Sunday: 3:00 AM to 6:00 AM (ET)
Holidays
Real-Time system processing is still available through Exchange EDI on the following holidays, but the Service and
Support office will be closed or not available. If New Years Day, Independence Day, or Christmas Day falls on a
weekend day, contact Service and Support for the exact day that Exchange EDI will be closed:
New Years Day
Memorial Day
Independence Day
Labor Day
Thanksgiving Day
Day after Thanksgiving
Christmas Day
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Getting Started with Exchange EDI

Working with Exchange EDI
Exchange EDI offers several methods to submit eligibility transactions to payers. Each has certain steps to begin the
process of submitting eligibility transactions.
Contact the Insurance Eligibility Support Team at support@exchangeedi.com for steps to begin submitting eligibility
transactions.
Certification and Testing Overview

Exchange EDI does not require certification of submitters and their transactions; however we do encourage sufficient
transaction testing.
Exchange EDI offers a separate document; the Testing Functionality Guide. The Testing Functionality guide specifically
outlines the process for testing transactions through three methods:
Connectivity Testing
Performance / Load Testing
Integration / DEV Testing
Testing is controlled by the username that is used when submitting transactions. All testing functionality is available at no
cost to the trading partner.
Please contact support@exchangeedi.com to receive password information for the testing accounts as well as the Testing
Functionality Guide.
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Connectivity with the Payer

Exchange EDI provides an efficient and secure exchange for healthcare transactions, which links payers, providers, and
business partners together. The Connectivity Guide contains technical specifications for the various methods that
Exchange EDI supports for communicating with our trading partners. Requests for the Connectivity Guide should be sent
to support@exchangeedi.com.
Exchange EDI supports multiple connectivity endpoints, as well as multiple transaction formats. This allows our trading
partners to choose communication methods which are the best fit for their particular integration needs. All available
communication methods and formats are outlined in this document.
Process Flow
Trading
Partner
EDI
XML
Common
Connectivity Interface
Exchange EDI
TransUnion
Healthcare
Clearinghouse
SNA
MQSeries
HTTPS
Socket
Web Service
Payer
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Payer
Payer
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Payer
10
Transmission Administrative Procedures

Real time requests must include a single inquiry or submission (e.g. one eligibility inquiry to one information source for
one patient). In this model the response from the message receiver is either an error response or the corresponding
response message.
Request formats are independent of response formats. You can submit an EDI request and get back an XML response. All
request / response format combinations are allowed where supported.
Appendix C: Supplemental Connectivity Information has been included to provide examples of message formats.
Request
EDI
ANSI ASC X12N 270 as defined in the HIPAA implementation guideline. 005010X279A1
Please refer to www.wpc-edi.com to obtain information on the HIPAA implementation guidelines. Exchange EDI
and payer specific requirements can be found in the Transaction Specific Information section of this Companion
Guide.
FlatXml
A custom Xml format has been created to enable non-EDI trading partners to submit health care transactions to
Exchange EDI. The Xml structure is fairly flat which allows for easy implementation. Please refer to the
Connectivity Guide for more information on the FlatXml format.
Response
EDI
Please refer to www.wpc-edi.com to obtain information on the HIPAA implementation guidelines. Exchange EDI
and payer specific requirements can be found in the Transaction Specific Information section of this Companion
Guide.
EdiXml
This format is a custom Xml response format which matches the looping structures of the equivalent EDI
transaction.
EDI segments are represented as Xml elements and EDI elements are represented as Xml attributes. Please refer
to the Connectivity Guide for more information on the EdiXml format.
EdiXmlExt
This format is based on the EdiXml format with extra information added into the response. All EDI code
attributes have an additional attribute which includes the English description of the EDI code.
Example: <REF REF01="SY" REF01_TEXT="Social Security Number" REF02="123456789" />
Please refer to the Connectivity Guide for more information on the EdiXmlExt format.
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EdiXmlExtHtml
There is a licensing fee that is associated with using this response type. Please contact your account manager for
more details.
This format includes the EdiXmlExt format, HTML representation of the response, and a response result code.
Please refer to the Connectivity Guide for more information on the EdiXmlExtHtml format.
VerboseXml
This format resembles the looping structure of the equivalent EDI transaction. The EDI codes are replaced with
English descriptions, all data is stored in Xml elements, and the element names are descriptive. Please refer to the
Connectivity Guide for more information on the VerboseXml format.
Re-Transmission Procedure
Authorization Errors:
If the HTTP Post Reply Message is not received within the timeout period, the trading partners system should
send a duplicate transaction no sooner than 90 seconds after the original attempt was sent.
If no response is received after the second attempt, the trading partners system should submit no more than 5
duplicate transactions within the next 15 minutes. If the additional attempts result in the same timeout
termination, the trading partner can contact Exchange EDI Insurance Eligibility Support to determine the length
and severity of the payers outage.
Server Errors:
It is possible that the HTTP server is not able to process a real time request. In this case, a standard HTTP 500
Internal Server Error will be returned. If a trading partner receives a response with this error code, they will need
to resubmit the request at a later time, because this indicates that Exchange EDI never processed this message.
Communication Protocol Specifications

All primary connectivity endpoints are based on the HTTP protocol. There are two different primary endpoints available;
URL get or post and Xml SOAP (web services).
In some circumstances a trading partner may not be able to make a HTTP connection. An example would be trading
partners that only support a TCP/IP sockets based connection. If a trading partner has a specific connectivity need outside
of the primary two HTTP endpoints they should contact the Exchange EDI technical support contact.
All connectivity endpoints have been tested with various integration technologies including .NET, Java EE and others.
Web Services (XML SOAP) Submission Portal

The submission portal web service is used to submit and retrieve healthcare transactions. There are two main
communication methods the submission portal uses which are synchronous and asynchronous. The Exchange EDI
preferred method for real-time transactions is synchronous.
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Synchronous Transactions
A single web method is called and the connection is kept open until a response is returned. One of the advantages
of this method of communication is you do not have to rely on unique identifiers to match up your request to the
response.
Asynchronous Transactions
Two web method calls are required to complete a transaction. The first call submits the transaction and the second
call retrieves the response, if available. Although this requires keeping track of unique identifiers for each
transaction, it does allow for automatic resubmission of transactions by Exchange EDI that timeout.
Web Service Description

The web service is SOAP 1.1 and 1.2 compliant.
URL: https://services.meddatahealth.com/submissionportal/submissionportal.asmx
WSDL URL: https://services.meddatahealth.com/submissionportal/submissionportal.asmx?WSDL
Security is handled through the use of a SOAP header. This SOAP header will contain the username and password
provided to you by Exchange EDI. The WSDL provides the format for the header. It must be provided for each of the web
methods that you call.
<SecurityHeader>
<UserName>ABC</UserName>
<Password>123</Password>
</SecurityHeader>
Web Methods
SubmitSync (Preferred Method)
SubmitAsync
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GetResponses
GetResponsesBySubmissionID
GetResponsesByTrackingID
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URL Description
URL: https://services.meddatahealth.com/clients/default/submit.aspx
Parameters can be either posted in a form or passed in on the query string of the URL.
Passwords
If the username and/or password included in the request are not valid, an HTTP 403 Forbidden error response with no data
content will be returned.
Please contact support@exchangeedi.com to receive password information for the testing accounts as well as the Testing
Functionality Guide.
Please contact support@exchangeedi.com for web portal user name/password assistance.
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Contact Information
Exchange EDI Insurance Eligibility Support
Email: support@exchangeedi.com
Phone: (877) 732-6853
Hours of Operation: 8am to 5pm EST
Contact us for:
Questions regarding 270/271 transactions

Documentation requests
Testing process and credentials
Exchange EDI Enrollment and Customer Support

Email: support@exchangeedi.com
Phone: (877) 633-3282
Hours of Operation: 8am to 5pm EST
Contact us for:
Web portal related questions

Medicare NPI validation
User name and password
Payer specific provider enrollments
Applicable Websites
Exchange EDI: http://www.exchangeedi.com
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Control Segments and Envelopes

Interchange Information
Interchange requirements are not strict. As long as the interchange is properly formatted, we will accept the
transaction. Security and identification are handled by the transport method and / or any logins associated with
the communication method. For example, a web services request will be identified by the SOAP security
header that is required and not any values in the interchange.
Dates must be in the CCYYMMDD format.
Delimiters
There are no restrictions on delimiters you can use when exchanging transactions with Exchange EDI. Use
caution when trying to use a delimiter that might be repeated in a data element. One of the more common
choices is:
Segment: ~ Element: *
that were used for the request.
Sub Element: : The response interchange will contain the same delimiters
ISA-IEA
If you need to configure your system for specific interchange values you can use the following table. These
values are not required in order to exchange transactions with Exchange EDI.
Element Name
Min
Max
Type
Codes and Values
ISA01
ID
00
ISA02
10
10
AN
ISA03
ID
00
ISA04
10
10
AN
ISA05
ID
ZZ
ISA06
15
15
AN
User Defined
ISA07
ID
30
ISA08
15
15
AN
204202692
ISA Segment
Data Type:
N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code
The sender ID, ISA06, is a User-Defined field. You can use this field to identify your company, or a client
code on your transactions. The sender and receiver ID values will be swapped and echoed back in the
response transmission. If you have any interchange specific requirements for ISA01-ISA04, we will
support those. The GS application sender and receiver ID values will also be swapped and echoed back in
the response.
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GS-GE
Exchange EDI does not require specific information for this segment. Exchange EDI automatically populates the correct,
required information to send to each payer.
Transactions are expected to have the minimum data populated as required by the implementation guide.
ST-SE
Exchange EDI does not require specific information for this segment. Exchange EDI automatically populates the correct,
required information to send to each payer.
Transactions are expected to have the minimum data populated as required by the implementation guide.
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Payer Specific Business Rules and Limitations

Search Options
The 270 transactions have the flexibility for allowing a variety of patient information. In the Transaction Specific
Information section of this Companion Guide, you will find that multiple Search Options may be defined. The data
elements are then listed in conjunction with the Loops and Segments that are required. Payer edits for specific fields are
also documented, i.e. fields that require numeric or alphanumeric elements.
Patients may be identified in either Loop 2100C or 2100D. If the Patient has a unique ID number then that person should
be considered the Subscriber. Only Loop 2100C should be sent for identification purposes.
If the Payer does not assign a unique identifier then the Subscriber and Dependents must be identified in Loops 2100C
and 2100D.
Data Usage
There are two levels in which the 270 transactions are divided:
The Header Level contains the transactions structure information; i.e. ISA and GS Segments.
The Detail Level contains specific insurer, insured, dependent and requestor information. There are four different ways in
which the Segments are utilized. Each HL is assigned a number identifying its purpose.
Loop 2000A: Information Source Payer Level.

The Exchange EDI Payer ID should be used to properly route requests to the Payer. Download the most recent payer list
from https://www.meddatahealth.com/pdf/payer_list.pdf
Loop 2000B: Information Receiver Provider Level

This is where the Submitters will identify themselves to the Payer by using either their assigned National Provider
Identifier, Payer assigned Provider Identifier or Federal Tax ID Number. (This depends on the specific payer.)
Loop 2000C: Subscriber Level

This loop is used to identify the Insured Member/Subscriber data elements. Only loop 2100C must be sent for
identification if the Patient has a unique identifier.
Loop 2000D: Dependent Level

This loop is used to identify Dependent data elements. If the Payer does not assign a unique identifier then the Subscriber
and Dependents must be identified in loops 2100C and 2100D.
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Acknowledgements
Submitters will receive only one of the following responses when submitting a 270 transaction:
TA1 (X12) when the ISA-IEA envelope cannot be processed;
999 when submitted 270 does not pass HIPAA validation; or
The 271 is returned in all other cases to indicate the members coverage.
Transaction Specific Information

The following section includes the payer sheets that describe the specific information, beyond the ASC X12
implementation guide, required by the payer.
Each payer sheet includes transaction specific information pertinent to that payer. Specific information includes the
unique Exchange EDI Payer ID, specific provider identifying information, subscriber and dependent identification
information, and specific service type codes accepted for each payer.
Exchange EDI works through various channels, partners, and direct with payers to obtain eligibility responses. We strive
to uphold all facets of regulations mandated under the Health Insurance Portability and Accountability Act (HIPAA).
Exchange EDI strives to keep this documented as changes occur and communicated by the payers or through our channel
partners. Keep in mind that each payer differs in their requirements and that Exchange EDI will update this document as
changes are received in a timely fashion.
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Aetna 10004
Search Options
Element 2
Element 3
Option
Element 1
Subscriber
Member ID (CUMB
ID)
Subscriber
Member ID (HMO)
Subscriber
Member ID (SSN)
Date of Birth
Subscriber
SSN
Date of Birth
Subscriber
Last Name
First Name
Dependent
Sub: Member ID
(CUMB ID)
Dep: Date of Birth
Dependent
Sub: Member ID
(SSN)
Dep: Date of Birth
Dependent
Sub: SSN
Dep: Date of Birth
Dependent
Sub: Last Name
Sub: First Name
Sub: Member ID
(CUMB ID)
Dep: Last Name
10 Dependent
Element 4
Element 5
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Dep: First Name
Dep: Date of Birth
Date of Birth
Date of Birth
Loop ID
2100A
Reference Element Name

NM1
Information Source
Codes
Length Notes/Comments
2100A
NM108
Identification Code Qualifier
PI
2100A
NM109
Payer ID
10004
2100B
NM1
Information Receiver
2100B
NM103
Name Last or Organization Name
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Exchange EDI Payer ID
60
21
2100B
NM108
Information Receiver ID Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
2100C
XX
2
10
National Provider ID
Last Name
60
Search options: #5 and #9
NM104
First Name
35
NM108
MI
2
Search options: #1, #6, and #10
2100C
NM109
Member ID (CUMB ID)
2100C
NM108
12
MI
Note: CUMB ID is for Non-HMO

line of business. It will be
identified on the ID card by a
leading W; i.e. W123456789-01.
Omit any dashes.
2
Search Option: #2
2100C
NM109
Member ID (HMO)
2100C
NM108
2100C
NM109
Member ID (SSN)
2100C
REF01
Reference Identification Qualifier
2100C
REF02
SSN
2100C
REF01
2100C
REF02
Group Number
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13
MI
2
9
SY
2
9
6P
Note: HMO Subscriber ID is

captured via swipe, or if the ID is
8 digits with at least one alpha
character, or if the Member ID
card specifies HMO or POS.
2
17
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22
Search options:
2100C
DMG02
Date of Birth
CCYYMMDD
8
#1, #3, #4, and #5
Up to 2 years in the Past.
2100C
DTP03
Service Date
CCYYMMDD
No Future Dates allowed.

Date Ranges are allowed
2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
60
2100D
NM104
First Name
35
2100D
REF01
2100D
REF02
Group Number
2100D
DMG02
Date of Birth
6P
2
17
CCYYMMDD
Search options:#6, #7, #8, #9, #10
Up to 2 years in the Past.

2100D
DTP03
Service Date
CCYYMMDD

Date Ranges are allowed
2100D
EQ01
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Service Type Code
35
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AFLAC Dental 10398

Search Options
# Option
Element 1
Element 2
Element 3
Element 4
1 Subscriber
Member ID
Last Name
First Name
Date of Birth
2 Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10398
2100B
NM1
2100B
NM103
Name Last or Organization Nam
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
20
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD

No Date Ranges allowed
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2100C
EQ01
Service Type Code
30
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
30
X12N/005010/270 v1.1
25
Alan Sturm and Associates - Dental - 10798
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10798
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
Reference Indentification Qualifier
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Provider Tax ID Required
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

No Date Ranges allowed.
2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
26
Altus Dental - 10786
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10786
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
27
BCBS of Alabama 10025
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
Identification Code Qualifier PI
2100A
NM109
Payer ID
2100B
NM1
2100B
NM103
Name Last or Organization

Name
2100B
NM108
Information Receiver ID
Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
10025
60
XX
10
Last Name
24
Search Option: #1
NM104
First Name
24
Search Option: #1
2100C
NM108
Identification Code Qualifier MI
2100C
NM109
Member ID
24
2100C
DMG02
Date of Birth
Search Option: #1
April 3, 2014
CCYYMMDD
X12N/005010/270 v1.1
28
Up to 1 year in the Past is

allowed.
2100C
DTP03
Service Date
CCYYMMDD
Future search is not allowed.

Date ranges are not allowed.
2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
24
Search Option: #2
2100D
NM104
First Name
24
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
CCYYMMDD

allowed.
2100D
DTP03
Dependent Date
CCYYMMDD

2100D
April 3, 2014
EQ01
Service Type Code
35
X12N/005010/270 v1.1
29
BCBS of Alabama (Institutional) 10609

Search Options
#
Option
Element 1
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
2100B
NM109
NM1
Payer ID
10609
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
Last Name
24
Search Option: #1
NM104
First Name
24
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
24
CCYYMMDD 8

Search Option: #1
allowed.
2100C
DTP03
Service Date
CCYYMMDD 8

Date ranges are allowed.
April 3, 2014
X12N/005010/270 v1.1
30
2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
24
Search Option: #2
2100D
NM104
First Name
24
Search Option: #2
2100D
DMG02
Date of Birth
CCYYMMDD 8
Search Option: #2
allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
31
BCBS of Arizona 10027
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10027
2100B
NM1
2100B
NM103

Name
2100B
NM108
Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
10
NPI if NM108 = XX
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
12
CCYYMMDD 8

Search Option: #1
Up to 14 days in the Past is allowed.
2100C
DTP03
Service Date
CCYYMMDD 8
Future date is allowed.

April 3, 2014
X12N/005010/270 v1.1
32
2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
CCYYMMDD 8
Search Option: #2
Up to 14 days in the Past is allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
Future date is allowed.

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
33
BCBS of Arkansas 10028
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Note: Health Advantage HMO can be accessed through BCBS AR.

Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10028
2100B
NM1
2100B
NM103

Name
2100B
NM108
Qualifier
2100B
NM109
NPI, Provider ID
Notes/Comments
60
XX, SV
Provider ID if NM108 = SV
10
NPI if NM108 = XX
2100B
REF01
Reference Identification
Qualifier
2100B
REF02
Submitter ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
2100C
EO
10
Five character ID beginning with E
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
NM108
April 3, 2014
MI
X12N/005010/270 v1.1
34
2100C
NM109
Member ID
20
2100C
REF01
Qualifier
2100C
REF02
SSN
2100C
DMG02
Date of Birth
SY
9
CCYYMMDD 8
Search Option: #1
Up to 1 year in the Past is allowed.
2100C
DTP03
Service Date
CCYYMMDD 8

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
REF01
Qualifier
2100D
REF02
SSN
2100D
DMG02
Date of Birth
SY
9
CCYYMMDD 8
Search Option: #2
Up to 1 year in the Past is allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
35
BCBS of Central New York 10461
Option
Element 1
Element 2
Search Options
Element 3
Subscriber
Member ID
Last Name
Dep: Last Name
Element 4
Element 5
First Name
Date of Birth
Gender
Dep: First Name
Dep: Date of Birth
Dep: Gender
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10461
2100B
NM1
2100B
NM103

Name
2100B
NM108
Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
10
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
15
CCYYMMDD 8

Search Option: #1
M = Male
2100C
DMG03
Gender
Search Option #1
F = Female
April 3, 2014
X12N/005010/270 v1.1
36
Past Dates allowed.

2100C
DTP03
Service Date
CCYYMMDD 8
Future Dates allowed.

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
60
Search Option: #2
2100D
NM104
First Name
35
Search Option: #2
2100D
DMG02
Date of Birth
CCYYMMDD 8
Search Option: #2
M = Male
2100D
DMG03
Gender
Search Option: #2
F = Female
Past Dates allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
37
BCBS of Colorado (Wellpoint Anthem) 10029
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10029
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
80
CCYYMMDD 8
X12N/005010/270 v1.1
Alphanumeric subscriber ID as it
appears on the front of the ID
card and must include the alpha
prefix as submitted.
Search Option: #1
38

2100C
DTP03
Service Date
CCYYMMDD 8

2100C
EQ01
Service Type Code
2100D
NM1
Dependent Name
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
2100D
35
CCYYMMDD 8
Search Option: #2
2100D
DTP03
Dependent Date
CCYYMMDD 8

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
39
BCBS of Connecticut (Wellpoint Anthem) 10030
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Loop ID
Reference
Element Name
2100A
NM1
Information Source
2100A
NM108
2100A
Element 3
Element 4
Codes
Length
PI
NM109
Payer ID
10030
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
80
CCYYMMDD 8
X12N/005010/270 v1.1
Search Option: #1
40

2100C
DTP03
Service Date
CCYYMMDD 8

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
CCYYMMDD 8
Search Option: #2
2100D
DTP03
Dependent Date
CCYYMMDD 8

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
41
BCBS of Georgia 10032
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10032
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
MI
80
CCYYMMDD 8
X12N/005010/270 v1.1

Search Option: #1
42

2100C
DTP03
Service Date
CCYYMMDD 8

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
CCYYMMDD 8
Search Option: #2
2100D
DTP03
Dependent Date
CCYYMMDD 8

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
43
BCBS of Indiana (Wellpoint Anthem) 10258
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10258
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
2100C
DMG03
Gender
MI
2
80
CCYYMMDD 8

Search Option: #1
M=Male
1
Optional
F=Female
April 3, 2014
X12N/005010/270 v1.1
44

2100C
DTP03
Service Date
CCYYMMDD 8

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
CCYYMMDD 8
Search Option: #2
M=Male
2100D
DMG03
Gender
Optional
F=Female
2100D
DTP03
Dependent Date
CCYYMMDD 8

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
45
BCBS of Kansas 10034
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10034
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
20
CCYYMMDD 8

Search Option: #1
Up to 2 years in the Past
2100C
DTP03
Service Date
CCYYMMDD 8
Only Current Month for Future

dates
April 3, 2014
X12N/005010/270 v1.1
46
2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
CCYYMMDD 8
Search Option: #2
2100D
DTP03
Dependent Date
CCYYMMDD 8

dates
2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
47
BCBS of Kansas City 10473
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10473
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
20
CCYYMMDD 8

Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD 8

dates
April 3, 2014
X12N/005010/270 v1.1
48
2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
CCYYMMDD 8
Search Option: #2
2100D
DTP03
Dependent Date
CCYYMMDD 8

dates
2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
49
BCBS of Kentucky (Wellpoint Anthem) 10259
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10259
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
80
CCYYMMDD 8
X12N/005010/270 v1.1
Search Option: #1
50

2100C
DTP03
Service Date
CCYYMMDD 8

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
CCYYMMDD 8
Search Option: #2
2100D
DTP03
Dependent Date
CCYYMMDD 8

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
51
BCBS of Maine (Wellpoint Anthem) 10036
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10036
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
80
CCYYMMDD 8
X12N/005010/270 v1.1
Search Option: #1
52

2100C
DTP03
Service Date
CCYYMMDD 8

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
CCYYMMDD 8
Search Option: #2
2100D
DTP03
Dependent Date
CCYYMMDD 8

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
53
BCBS of Michigan (Institutional) 10519
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A

NM1
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10519
2100B
NM1
2100B
NM103

Name
2100B
NM108
Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
10
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
Qualifier
2100C
REF02
Group Number
April 3, 2014
MI
2
20
6P
30
X12N/005010/270 v1.1
54
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
55
BCBS of Michigan (Professional) 10038
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A

NM1
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10038
2100B
NM1
2100B
NM103

Name
2100B
NM108
Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
10
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
Qualifier
2100C
REF02
Group Number
April 3, 2014
MI
2
20
6P
30
X12N/005010/270 v1.1
56
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
REF01
Qualifier
2100D
REF02
Group Number
2100D
DMG02
Date of Birth
CCYYMMDD
2100D
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
Service Type Code
35
April 3, 2014
35
6P
30
X12N/005010/270 v1.1
Search Option: #2
57
BCBS of Missouri (Wellpoint Anthem) 10322
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10322
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
58
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
59
BCBS of Nevada (Wellpoint Anthem) 10260
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10260
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
the alpha prefix as
submitted.
60
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
61
BCBS of New Hampshire (Wellpoint Anthem) 10261
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10261
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
the alpha prefix as
submitted.
62
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
2100D
NM1
Dependent Name
2100D
NM103
2100D
2100D
35
Last Name
35
Search Option: #2
NM104
First Name
25
Search Option: #2
DMG02
Date of Birth
Search Option: #2
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
63
BCBS of New York (Empire) 10043
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10043
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
the alpha prefix as
submitted.
64
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
65
BCBS of New York (Excellus) 10323
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10323
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
80
Search Option: #1
Up to 90 days in the Past
2100C
DTP03
Service Date
CCYYMMDD

90 day Date Ranges allowed
April 3, 2014
X12N/005010/270 v1.1
66
2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
CCYYMMDD
Up to 90 days in the Past

2100D
DTP03
Dependent Date
CCYYMMDD

90 day Date Ranges allowed
2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
67
BCBS of North Carolina 10383
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Subscriber
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Element 3
Element 4
Date of Birth
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10383
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Dep: Date of Birth
Notes/Comments
60
XX
10
Last Name
60
NM104
First Name
35
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
MI
CCYYMMDD
X12N/005010/270 v1.1
2
12
68
Up to 3 years prior to the

current date in the Past
2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
60
Search Option: #3
2100D
NM104
First Name
35
Search Option: #3
2100D
DMG02
Date of Birth
Search Option: #3
CCYYMMDD
Up to 3 years prior to the

current date in the Past
2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
69
BCBS of Ohio (Wellpoint Anthem) 10044
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10044
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
the alpha prefix as
submitted.
70
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
71
BCBS of South Carolina 10047
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
Subscriber
Member ID
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dependent
Sub: Member ID
Dep: Date of Birth
Element 3
Element 4
First Name
Date of Birth
Dep: First Name
Dep: Date of Birth
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10047
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
FI, XX
Federal Tax ID, NPI
10
Federal Tax ID if NM108 =

FI
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
60
Search Option: #1
2100C
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
MI
2
Search options:
17
#1, #2, #3, and #4
April 3, 2014
X12N/005010/270 v1.1
72
2100C
DMG02
Date of Birth
CCYYMMDD

2100C
DTP03
Service Date
CCYYMMDD
Up to 1 year in the Future

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #3
2100D
NM104
First Name
25
Search Option: #3
2100D
DMG02
Date of Birth
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD
Up to 1 year in the Future

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
73
BCBS of the Rochester Area (NY) 10469
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Last Name
First Name
Date of Birth
Gender
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Dep: Gender
Element 4
Element 5
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10469
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
2100C
DMG03
Gender
MI
CCYYMMDD
2
15
Search Option: #1
Search Option: #1
M=Male
F=Female
April 3, 2014
X12N/005010/270 v1.1
74
Up to 1 year in the Past.

2100C
DTP03
Service Date
CCYYMMDD
Up to 30 days in the Future.

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
60
Search Option: #2
2100D
NM104
First Name
35
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
Search Option: #2
CCYYMMDD
M=Male
2100D
DMG03
Gender
F=Female

2100D
DTP03
Dependent Date
CCYYMMDD
Up to 30 days in the Future.

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
75
BCBS of Utica-Watertown (NY) 10470
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Last Name
First Name
Date of Birth
Gender
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Dep: Gender
Element 4
Element 5
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10470
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
2100C
DMG03
Gender
MI
CCYYMMDD
2
15
Search Option: #1
Search Option: #1
M=Male
F=Female
April 3, 2014
X12N/005010/270 v1.1
76

2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
60
Search Option: #2
2100D
NM104
First Name
35
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
Search Option: #2
CCYYMMDD
M=Male
2100D
DMG03
Gender
F=Female

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
77
BCBS of Virginia (Wellpoint Anthem) 10049
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10049
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
the alpha prefix as
submitted.
78
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
79
BCBS of Wisconsin (Wellpoint Anthem) 10299
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Codes
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10299
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
the alpha prefix as
submitted.
80
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
EQ01
Service Type Code
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
Search Option: #2
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
81
Blue Benefit Administrators of Mass 10803
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10803
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
20
CCYYMMDD 8

Search Option: #1
Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD 8

April 3, 2014
X12N/005010/270 v1.1
82
Only (1) EQ01 segment per

transaction
Last Name
35
Search Option: #2
NM104
First Name
25
Search Option: #2
DMG02
Date of Birth
2100C
EQ01
Service Type Code
2100D
NM1
Dependent Name
2100D
NM103
2100D
2100D
35
CCYYMMDD 8
Search Option: #2
Past Dates allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1

transaction
83
Blue Cross of California 10051
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10051
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
Provider ID, NPI
Notes/Comments
60
SV, XX
2
10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Option: #1
2100C
NM104
First Name
25
Search Option: #1
2100C
NM108
MI
2
2100C
NM109
April 3, 2014
Member ID
12
X12N/005010/270 v1.1
the alpha prefix as
submitted.
84
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD


transaction
Last Name
35
Search Option: #2
NM104
First Name
25
Search Option: #2
DMG02
Date of Birth
Search Option: #2
2100C
EQ01
Service Type Code
2100D
NM1
Dependent Name
2100D
NM103
2100D
2100D
35
CCYYMMDD

2100D
DTP03
Dependent Date
CCYYMMDD

2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1

transaction
85
Brokers National - Dental - 10783
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10783
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
86
Care Improvement Plus 10806
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Date of Birth
Subscriber
Member ID
Last Name
Subscriber
SSN
Date of Birth
Subscriber
SSN
Last Name
First Name
Subscriber
Last Name
First Name
Date of Birth
State
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 4
First Name
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10806
2100B
NM1
2100B
NM103
2100B
NM108
Information Receiver ID Code Qualifier
2100B
NM109
April 3, 2014
Element 5
NPI/Federal Tax ID/Provider ID
X12N/005010/270 v1.1
Dep: State
Notes/Comments
60
XX, FI, SV
10
National Provider ID if
NM108=XX. Federal Tax
ID if NM108=FI.
Provider ID if
87
NM108=SV.
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Options #2, #3,

#5, #6
2100C
NM104
First Name
25

#5, #6
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
2100C
REF02
Social Security Number
2100C
REF01
2100C
REF02
Group Number
Optional, but
recommended.
2100C
N402
State
Search Option #5
2100C
DMG02
Date of Birth

#4, #6
MI
SY
2
9
6P
CCYYMMDD

#3, #6, #7
Search Options #3, #4
Up to 18 months in the
Past
2100C
DTP03
Service Date
CCYYMMDD
Up to the end of the

current month in the
Future
Date Ranges allowed
2100C
EQ01
Service Type Code
2100D
NM1
Dependent Name
April 3, 2014
X12N/005010/270 v1.1
35
88
2100D
NM103
Last Name
35
Search Options #7
2100D
NM104
First Name
25
2100D
REF01
2100D
REF02
2100D
REF01
2100D
REF02
Group Number
30
Optional, but
recommended.
2100D
N402
State
Search Option #8
2100D
DMG02
Date of Birth
SY
2
9
6P
CCYYMMDD
Optional
Past
2100D
DTP03
Dependent Date

Future
Date Ranges allowed
2100D
EQ01
April 3, 2014
Service Type Code
X12N/005010/270 v1.1
35
89
CIGNA/Great West Healthcare 10062
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Subscriber
Member ID
Last Name
Date of Birth
Subscriber
Member ID
Last Name
First Name
Subscriber
Member ID
Date of Birth
Subscriber
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dependent
Sub: Member ID
Dep: Last Name
Dep: Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dependent
Sub: Member ID
Dep: Date of Birth
10
Dependent
Dep: Last Name
Dep: First Name
Element 3
Element 4
Date of Birth
Dep: Date of Birth
Dep: Date of Birth
NOTE: Great West Healthcare has been merged with Cigna

Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10062
2100B
NM1
2100B
NM103
April 3, 2014
X12N/005010/270 v1.1
Notes/Comments
60
90
2100B
NM108
2100B
NM109
Federal Tax ID, NPI
FI, XX
Federal Tax ID if NM108 = FI

10
NPI if NM108 = XX
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
Search Options: #1, #2, #3, #5
2100C
NM104
First Name
25
Search Options: #1, #3, #5
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
24
CCYYMMDD 8
Search Options: #1, #2, #3, #4,

#6, #7, #8, #9
There is no limit on Past date
searches. All historical data is
stored.
2100C
DTP03
Service Date
CCYYMMDD 8
Up to 30 days in the future.
2100C
EQ01
Service Type Code
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
2100D
NM104
First Name
25
Search Options: #6, #8, #10
2100D
DMG02
Date of Birth
CCYYMMDD 8
2100D
DTP03
Dependent Date
CCYYMMDD 8
April 3, 2014
35
X12N/005010/270 v1.1
There is no limit on Past date

searches. All historical data is
91
stored.
Up to 30 days in the future.
2100D
EQ01
April 3, 2014
Service Type Code
35
X12N/005010/270 v1.1
92
DeCare Dental Health Insurance - 10780
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10780
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
93
Delta Dental
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Payer Name
Delta Dental Payer Codes

Payer ID
Payer Name
Payer ID
Delta Dental Ins. Co. - Alabama
10709
Delta Dental of Minnesota
10725
Delta Dental Ins. Co. - Florida
10710
Delta Dental of Nebraska
10726
Delta Dental Ins. Co. - Georgia
10711
Delta Dental of New Jersey
10727
Delta Dental Ins. Co. - Louisiana
10712
Delta Dental of New Mexico
10728
Delta Dental Ins. Co. - Mississippi
10713
Delta Dental of New York
10729
Delta Dental Ins. Co. - Montana
10714
Delta Dental of North Carolina
10730
Delta Dental Ins. Co. - Nevada
10715
Delta Dental of North Dakota
10731
Delta Dental Ins. Co. - Texas
10716
Delta Dental of Ohio
10732
Delta Dental Ins. Co. - Utah
10717
Delta Dental of Pennsylvania
10733
Delta Dental of California
10705
Delta Dental of Rhode Island
10734
Delta Dental of Colorado
10718
Delta Dental of Tennessee
10735
Delta Dental of Connecticut
10719
Delta Dental of Virginia
10736
Delta Dental of Delaware
10720
Delta Dental of Washington DC
10737
Delta Dental of Hawaii
10721
Delta Dental of Washington State
10738
Delta Dental of Indiana
10722
Delta Dental of West Virginia
10739
Delta Dental of Maryland
10723
DeltaCare USA - Claims
10740
Delta Dental of Michigan
10724
DeltaCare USA - Encounters
10741
Note: Delta Dental of Minnesota includes Delta MN Capitation, Delta MN DeltaCare Claims, Delta MN National Claims,
Delta MN/Wells Fargo Claims, Delta USA Dental Claims Plan 005 MN
April 3, 2014
X12N/005010/270 v1.1
94
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
2100A
NM108
PI
2
2100A
NM109
Payer ID
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
Reference Indentification
Qualifier
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
See Delta Dental Payer

Codes table above
60
XX
2
10
TJ
NPI if NM108 = XX
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
95
Dental Benefit Providers - 10787
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10787
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
96
Employee Benefit Services - Dental - 10784
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10784
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
97
Evercare 10807
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Date of Birth
Subscriber
Member ID
Last Name
Subscriber
SSN
Date of Birth
Subscriber
SSN
Last Name
First Name
Subscriber
Last Name
First Name
Date of Birth
State
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 4
First Name
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10807
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
April 3, 2014
Element 5
X12N/005010/270 v1.1
Dep: State
Notes/Comments
60
XX, FI, SV
10
ID if NM108=FI.
Provider ID if
NM108=SV.
98
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35

#5, #6
2100C
NM104
First Name
25

#5, #6
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
2100C
REF02
2100C
REF01
2100C
REF02
Group Number
Optional, but
recommended.
2100C
N402
State
Search Option #5
2100C
DMG02
Date of Birth

#4, #6
MI
SY
2
9
6P
CCYYMMDD

#3, #6, #7
Past
2100C
DTP03
Service Date
CCYYMMDD

Future
Date Ranges allowed
2100C
EQ01
Service Type Code
2100D
NM1
Dependent Name
2100D
NM103
Last Name
April 3, 2014
35
35
X12N/005010/270 v1.1
Search Options #7
99
2100D
NM104
First Name
25
2100D
REF01
2100D
REF02
2100D
REF01
2100D
REF02
Group Number
30
Optional, but
recommended.
2100D
N402
State
Search Option #8
2100D
DMG02
Date of Birth
SY
2
9
6P
CCYYMMDD
Optional
Past
2100D
DTP03
Dependent Date

Future
Date Ranges allowed
2100D
EQ01
April 3, 2014
Service Type Code
X12N/005010/270 v1.1
35
100
Flex Compensation - Dental - 10799
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10799
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
101
Florida Combined Life - Dental - 10811
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10811
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
102
Group Health Cooperative of South Central Wisconsin - Dental - 10781
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10781
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
103
Guardian Life Insurance Co. of America - Dental - 10788
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10788
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
104
Hawaii Medical Assurance Association - Dental - 10785
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10785
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
105
HealthPlan of Nevada 10804
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Date of Birth
Subscriber
Member ID
Last Name
Subscriber
SSN
Date of Birth
Subscriber
SSN
Last Name
First Name
Subscriber
Last Name
First Name
Date of Birth
State
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 4
First Name
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10804
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
April 3, 2014
Element 5
X12N/005010/270 v1.1
Dep: State
Notes/Comments
60
XX, FI, SV
10
ID if NM108=FI.
Provider ID if
NM108=SV.
106
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35

#5, #6
2100C
NM104
First Name
25

#5, #6
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
2100C
REF02
2100C
REF01
2100C
REF02
Group Number
Optional, but
recommended.
2100C
N402
State
Search Option #5
2100C
DMG02
Date of Birth

#4, #6
MI
SY
2
9
6P
CCYYMMDD

#3, #6, #7
Past
2100C
DTP03
Service Date
CCYYMMDD

Future
Date Ranges allowed
2100C
EQ01
Service Type Code
2100D
NM1
Dependent Name
2100D
NM103
Last Name
April 3, 2014
35
35
X12N/005010/270 v1.1
Search Options #7
107
2100D
NM104
First Name
25
2100D
REF01
2100D
REF02
2100D
REF01
2100D
REF02
Group Number
30
Optional, but
recommended.
2100D
N402
State
Search Option #8
2100D
DMG02
Date of Birth
SY
2
9
6P
CCYYMMDD
Optional
Past
2100D
DTP03
Dependent Date

Future
Date Ranges allowed
2100D
EQ01
April 3, 2014
Service Type Code
X12N/005010/270 v1.1
35
108
Healthsource Provident - Dental - 10789
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10789
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
109
Hershey Healthsmile - Dental - 10795
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10795
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
110
MetLife Dental - 10134
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10134
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
111
Patriot Dental - 10782
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10782
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
112
Provident Preferred Network - Dental - 10790
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10790
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
113
Securian Dental - 10792
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10792
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
114
Securian/Patriot Dental - 10793
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10793
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
115
TennDent - 10794
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10794
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
116
UNICARE - Dental - 10791
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10791
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
117
United Healthcare 10002
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Date of Birth
Subscriber
Member ID
Last Name
Subscriber
SSN
Date of Birth
Subscriber
SSN
Last Name
First Name
Subscriber
Last Name
First Name
Date of Birth
State
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Dependent
Sub: Member ID
Dep: Last Name
Dep: First Name
Dep: Date of Birth
Element 4
Element 5
First Name
Dep: State
Note: UHC Payer ID 10002 supports Health Plan of Nevada and SierraHealth (UHC Nevada)
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10002
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
April 3, 2014
X12N/005010/270 v1.1
Notes/Comments
60
XX, FI, SV
10
ID if NM108=FI.
Provider ID if
NM108=SV.
118
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35

#5, #6
2100C
NM104
First Name
25

#5, #6
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
2100C
REF02
2100C
REF01
2100C
REF02
Group Number
Optional, but
recommended.
2100C
N402
State
Search Option #5
2100C
DMG02
Date of Birth

#4, #6
MI
SY
2
9
6P
CCYYMMDD

#3, #6, #7
Past
2100C
DTP03
Service Date
CCYYMMDD

Future
Date Ranges allowed
2100C
EQ01
Service Type Code
2100D
NM1
Dependent Name
2100D
NM103
Last Name
April 3, 2014
35
35
X12N/005010/270 v1.1
Search Options #7
119
2100D
NM104
First Name
25
2100D
REF01
2100D
REF02
2100D
REF01
2100D
REF02
Group Number
30
Optional, but
recommended.
2100D
N402
State
Search Option #8
2100D
DMG02
Date of Birth
SY
2
9
6P
CCYYMMDD
Optional
Past
2100D
DTP03
Dependent Date

Future
Date Ranges allowed
2100D
EQ01
April 3, 2014
Service Type Code
X12N/005010/270 v1.1
35
120
United Concordia Companies, Inc. - Dental - 10810
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10810
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
121
United Concordia Federal Employees Program - Dental - 10809
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10809
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
122
Wilson McShane - Dental - 10797
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10797
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
123
Zenith Administrators (MN) - Dental - 10796
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A

NM1
Information Source
Codes
2100A
NM108
PI
2100A
NM109
Payer ID
10796
2100B
NM1
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
2100C
DTP03
Service Date
CCYYMMDD

2100C
April 3, 2014
EQ01
Service Type Code

X12N/005010/270 v1.1
30, 35
2
124
Appendix A: Special Enrollment Payers

The payers listed below require Special Enrollment, and are not immediately available to providers. Special enrollment
includes a registration process with the particular payer as outlined below.
TransUnion Healthcare
ATTN: Enrollment
6100 Fairview Rd; Suite 1200
Charlotte, NC 28210
Email: enrollment_meddata@transunion.com Fax: 704-970-1436
Payer
BCBS of Alabama
BCBS of Michigan
April 3, 2014
Enrollment Process
Enrollment form must be completed and submitted to
TransUnion Healthcare.
Note: Once enrollment is completed, non-institutional
providers must send a taxonomy segment (PRV01=PC) for
their transactions to route correctly.
1) Go to https://editest.bcbsm.com/tpalogon.html
2)
Enter your TPA User ID and password.
a.
Note: If a provider is unable to login, that
means the user ID and password are invalid.
Provider should call BCBS MI to obtain their
correct user ID and password 800.542.0945,
option 3 or email EDISupport@bcbsm.com.
b.
Note: If a provider doesnt know their User
ID and password, they can contact BCBS MI at
800.542.0945, option 3 or email
EDISupport@bcbsm.com to obtain their TPA
User ID and PW.
3)
Once you are logged in, choose Professional Provider
Authorization or Institutional Provider Authorization.
4)
Then enter the following information:
a.
Provider ID (PIN) = LEAVE THIS FIELD
BLANK
b.
NPI = Providers NPI
c.
Source of Payment = Blue Cross Blue Shield
d.
Submitter ID = c0ina (thats a zero in there)
for Professional Providers. 204202692 for
Institutional Providers.
e.
Unique Receiver ID = LEAVE THIS
FIELD BLANK
f.
Provider email address = email address that
BCBS MI can send confirmation to.
g.
Click Submit
After doing all of the steps above, BCBS MI will send a
confirmation email that the enrollment will effective in 48
hours. The payer wont send another email. Transactions
should work in 48 hours.
X12N/005010/270 v1.1
Estimated Timeframe
2 weeks
48 hours, at discretion of
BCBS MI
125
Appendix B: Payer Maintenance Schedule

Use the following table to determine the payers time windows for maintenance.
ID
10004
10398
10798
Payer Name
Aetna
AFLAC Dental
Alan Sturm and Associates - Dental
10786
Altus Dental
10609
BCBS of Alabama (Institutional)
10027
10028
10461
10029
10030
10032
BCBS of Arizona
BCBS of Arkansas
BCBS of Central New York
BCBS of Colorado (Wellpoint)
BCBS of Connecticut (Wellpoint)
BCBS of Georgia
10258
BCBS of Indiana (Wellpoint)
10034
BCBS of Kansas
10473
BCBS of Kansas City
10259
BCBS of Kentucky (Wellpoint)
10036
BCBS of Maine (Wellpoint)
10519
BCBS of Michigan (Institutional)
10038
BCBS of Michigan (Professional)
10322
BCBS of Missouri (Wellpoint)
Down all day Sunday 12am 11:59pm (Eastern)
10260
BCBS of Nevada (Wellpoint)
No Stated Downtime
10261
BCBS of New Hampshire (Wellpoint)
No Stated Downtime
10043
BCBS of New York (Empire)
Sun 12am Sun 9pm Mon 12am Tue 3am Tue

12am Tue 12:45am Wed 12am Wed 12:45am Thu
12am 12:45 am Fri 12am Fri 12:45 am Sat 12 am
Sat 12:45 am and Sat 4pm 10:59 pm (Central)
10323
BCBS of New York (Excellus)
Mon Sat 5am 6am, Sun 4pm Mon 6am (Eastern)
10302
BCBS of North Carolina
April 3, 2014
Stated Downtime
Sunday 4:00 am 12:00 pm (Eastern)
No Stated Downtime
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Mon Fri 12:01 am 6:00 am, Sat 12:00 pm Mon
6:00 am (Central)
Sun 12:00am 12:00 pm (central)
Mon Sat 12am to 6am (Central) Sat (all day)
No Stated Downtime
No Stated Downtime
No Stated Downtime
Mon-Friday (4:45am-5:15am and 10:30pm-11pm);
Sat (4:45am-5:15am and 5:30pm-6pm); Sunday
(10am-10:30am and 5pm-5:30pm)
Sat 12 am - Mon 5am (Central)
Sun 6 pm 11:59 pm
Mon - Sat 12am 2am
All times Central
No Stated Downtime
Mon Sat 1:00 am 6:59 am, Sunday and Holidays
6:00 pm 7:00 am (Eastern)
Mon Sat 1:00 am 6:59 am, Sunday and Holidays
6:00 pm 7:00 am (Eastern)
Mon Sun 1am 4am (Eastern)
X12N/005010/270 v1.1
126
ID
10044
Payer Name
BCBS of Ohio (Wellpoint)
10047
BCBS of South Carolina
10469
BCBS of the Rochester Area (NY)
No Stated Downtime
10470
BCBS of Utica-Watertown (NY)
No Stated Downtime
10299
BCBS of Wisconsin (Wellpoint)
10051
10803
Blue Cross of California (Wellpoint)

Blue Benefit Administrators of Mass
10783
Brokers National - Dental
10806
Care Improvement Plus
10062
CIGNA
10780
DeCare Dental Health Insurance
10709
Delta Dental Ins. Co. - Alabama
10710
Delta Dental Ins. Co. - Florida
10711
Delta Dental Ins. Co. - Georgia
10712
Delta Dental Ins. Co. - Louisiana
10713
Delta Dental Ins. Co. - Mississippi
10714
Delta Dental Ins. Co. - Montana
10715
Delta Dental Ins. Co. - Nevada
10716
Delta Dental Ins. Co. - Texas
10717
Delta Dental Ins. Co. - Utah
10705
Delta Dental of California
10718
Delta Dental of Colorado
10719
Delta Dental of Connecticut
10720
Delta Dental of Delaware
April 3, 2014
Stated Downtime
Sunday 3:00pm-10:00pm (Eastern)
X12N/005010/270 v1.1
No Stated Downtime
No Stated Downtime
Mon Fri: 10pm 7am, Sat 8pm Sun 2pm, Sun
8pm Mon 7am (Eastern), Thurs 5:30am-8:00am
(MT),Sun 9:00am-12:00pm (MT)
(MT),Sun 9:00am-12:00pm (MT)
127
ID
10721
Payer Name
Delta Dental of Hawaii
10722
Delta Dental of Indiana
10723
Delta Dental of Maryland
10724
Delta Dental of Michigan
10725
Delta Dental of Minnesota
10726
Delta Dental of Nebraska
10727
Delta Dental of New Jersey
10728
Delta Dental of New Mexico
10729
Delta Dental of New York
10730
Delta Dental of North Carolina
10731
Delta Dental of North Dakota
10732
Delta Dental of Ohio
10733
Delta Dental of Pennsylvania
10734
Delta Dental of Rhode Island
10735
Delta Dental of Tennessee
10736
Delta Dental of Virginia
10737
Delta Dental of Washington DC
10738
Delta Dental of Washington State
10739
Delta Dental of West Virginia
10740
DeltaCare USA - Claims

10741
DeltaCare USA - Encounters
10787
Dental Benefit Providers
10784
Employee Benefit Services - Dental

April 3, 2014
X12N/005010/270 v1.1
Stated Downtime
128
ID
10807
Payer Name
Evercare
10811
Florida Combined Life - Dental
10781
Group Health Cooperative of South Central

Wisconsin - Dental

10788
Guardian Life Insurance Co. of America - Dental
10785
Hawaii Medical Assurance Association - Dental
10804
Health Plan of Nevada
10789
Healthsource Provident - Dental
10795
Hershey Healthsmile - Dental
10134
10782
MetLife Dental
Patriot Dental
10790
Provident Preferred Network - Dental
10792
Securian Dental
10793
Securian/Patriot Dental
10794
TennDent
10791
UNICARE - Dental
10810
United Concordia Companies, Inc. - Dental
10809
United Concordia Federal Employees Program Dental

(MT),Sun 9:00am-12:00pm (MT)
No Stated Downtime
10002
United Healthcare
10797
Wilson McShane - Dental
10796
Zenith Administrators (MN) - Dental
April 3, 2014
X12N/005010/270 v1.1
Stated Downtime
(MT),Sun 9:00am-12:00pm (MT)
Tues - Fri: 2:00 a.m. until 5:59 a.m., 6:00pm Sat until
6:00am Mon ET
Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm
(MT)
129
Appendix C: Transaction Examples

Request Formats
EDI
FlatXml
This format is a relatively flat xml format to provide easier access to Exchange EDI transaction processing. A listing of
the most commonly available elements are provided in the example request below. If there is a search field that is not
contained in the sample that is required, then please contact Exchange EDI and we will provide you with the name of the
field to use when submitting the request.
Some payers require provider specific information like PIN numbers or legacy provider numbers. That information must
be submitted in provider specific fields, a listed of payers and the required elements can be obtained by contacting
support.
Date of service should be in the format of CCYYMMDD-CCYYMMDD. If this is a single date you can use the same date
value for both. All other dates, like date of births, should be in the format of CCYYMMDD.
We can provide provider id lookup services for your providers. If you are accessing a payer that requires multiple ids we
will perform the look up for you if you provide us that information ahead of time. Otherwise you can submit them
yourself by requesting the names of the fields to supply the data in. If you do not supply a service type code a default of
30 is used.
Example FlatXml eligibility request:
<?xml version="1.0" encoding="UTF-8"?>
<requests>
<request requestType="Eligibility">
<trackingId>123456789</trackingId> [Alpha-numeric, max 30 characters]
<dateOfService>19900101-19900101</dateOfService> [numeric, min 8/max 17 characters]
<payerId>10000</payerId> [numeric, 5 characters]
<providerId>123456789</providerId> [Alpha-numeric, max 80 characters]
<requestVersion>X12_005010</requestVersion> [Alpha-numeric, max 10 characters]
<responseVersion>X12_005010</responseVersion> [Alpha-numeric, max 10 characters]
<providerLastNameOrgName>ProviderLastName</providerLastNameOrgName> [Alpha-numeric, max 35 characters]
<subscriberId>123456789ABC</subscriberId> [Alpha-numeric, max 80 characters]
<subscriberSSN>123456789</subscriberSSN> [Alpha-numeric, 9 characters]
<subscriberGroupNumber>12345</subscriberGroupNumber> [Alpha-numeric, max 30 characters]
<subscriberFirstName>JOHN</subscriberFirstName> [Alpha-numeric, max 25 characters]
<subscriberMiddleName>J</subscriberMiddleName> [Alpha-numeric, max 25 characters]
<subscriberLastName>SMITH</subscriberLastName> [Alpha-numeric, max 35 characters]
<subscriberSuffixName>JR</subscriberSuffixName> [Alpha-numeric, max 10 characters]
<subscriberGender>M</subscriberGender> [Alpha, 1 characters]
<subscriberDOB>19900101</subscriberDOB> [numeric, 8 characters]
<patientRelationCode>01</patientRelationCode> [numeric, max 2 characters]
<dependentSSN>123456789</dependentSSN> [numeric, 9 characters]
<dependentGroupNumber>12345</dependentGroupNumber> [Alpha-numeric, max 30 characters]
<dependentFirstName>MARY</dependentFirstName> [Alpha-numeric, max 25 characters]
<dependentMiddleName>J</dependentMiddleName> [Alpha-numeric, max 25 characters]
<dependentLastName>SMITH</dependentLastName> [Alpha-numeric, max 35 characters]
<dependentSuffixName>JR</dependentSuffixName> [Alpha-numeric, max 10 characters]
<dependentGender>F</dependentGender> [Alpha, 1 characters]
<dependentDOB>19900101</dependentDOB> [numeric, 8 characters]
<serviceTypeCode>30</serviceTypeCode> [numeric, max 2 characters]
</request>
</requests>
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Response Formats
EDI
ANSI ASC X12N 270 as defined in the HIPAA implementation guideline 005010X279A1.
EdiXml
EdiXml is a custom MedData xml representation of an EDI transmission. Current there is no xml schema available for
this response. Sample responses can be requested.
It follows the looping structure of health care EDI responses. EDI segments are presented as xml elements and EDI
elements are represented by XML attributes.
Sample Response:
<EdiTransmission>
<Interchange SegmentDelimiter="~" ElementDelimiter="*" SubElementDelimiter=">" RepeatingElementDelimiter="{">
<ISA ISA01="00" ISA02="
" ISA03="00" ISA04="
" ISA05="ZZ" ISA06="MEDDATA
" ISA07="ZZ" ISA08="MEDDATA
" ISA09="130809" ISA10="1219" ISA11="{" ISA12="00501" ISA13="000000001" ISA14="0" ISA15="P" ISA16=">">
<GS GS01="HB" GS02="MEDDATA" GS03="MEDDATA" GS04="20130809" GS05="121926" GS06="1" GS07="X"
GS08="005010X279A1">
<ST ST01="271" ST02="0001" ST03="005010X279A1">
<BHT BHT01="0022" BHT02="11" BHT03="ABC123" BHT04="20130809" BHT05="131926" />
<HL HL01="1" HL02="" HL03="20" HL04="1">
<NM1 NM101="PR" NM102="2" NM103="PAYER NAME" NM104="" NM105="" NM106="" NM107="" NM108="PI"
NM109="ABC123" />
<HL HL01="2" HL02="1" HL03="21" HL04="1">
<NM1 NM101="1P" NM102="2" NM103="SMITH" NM104="" NM105="" NM106="" NM107="" NM108="XX" NM109="ABC123">
<REF REF01="TJ" REF02="ABC123" />
</NM1>
<HL HL01="3" HL02="2" HL03="22" HL04="0">
<TRN TRN01="2" TRN02="ABC123" TRN03="9MEDDATACO" />
<NM1 NM101="IL" NM102="1" NM103="SMITH" NM104="JOHN" NM105="" NM106="" NM107="" NM108="MI"
NM109="ABC123">
<REF REF01="6P" REF02="ABC123" />
<N3 N301="123 RIDGE WAY" />
<N4 N401="CHARLOTTE" N402="NC" N403="28211" />
<DMG DMG01="D8" DMG02="19900101" DMG03="M" />
<DTP DTP01="291" DTP02="RD8" DTP03="19900101-99991231" />
<EB EB01="1" EB02="IND" EB03.1="30" EB04="PR" EB05="STANDARD">
<DTP DTP01="291" DTP02="RD8" DTP03="19900101-99991231" />
</EB>
<EB EB01="P">
<MSG MSG01="UNLESS OTHERWISE REQUIRED BY APPROPRIATE LAW, THIS NOTICE IS NOT A GUARANTEE OF
PAYMENT. BENEFITS ARE SUBJECT TO ALL CONTRACT LIMITATIONS AND THE MEMBER'S ELIGIBILITY STATUS ON THE DATE
OF SERVICE. PAID-TO-DATE AMOUNTS REFLECT ONLY FINALIZED CLAIMS." />
</EB>
<EB EB01="C" EB02="IND" EB03.1="30" EB04="" EB05="STANDARD" EB06="29" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="W" />
<EB EB01="C" EB02="FAM" EB03.1="30" EB04="" EB05="STANDARD" EB06="29" EB07="350" EB08="" EB09="" EB10=""
EB11="" EB12="W" />
EB11="" EB12="W">
<MSG MSG01="DOES NOT ACCUMULATE TOWARDS THE CATASTROPHIC OUT-OF-POCKET MAXIMUM" />
</EB>
EB11="" EB12="W">
</EB>
<EB EB01="G" EB02="" EB03.1="30" EB04="" EB05="STANDARD" EB06="29" EB07="2281" EB08="" EB09="" EB10=""
EB11="" EB12="Y" />
<EB EB01="G" EB02="" EB03.1="30" EB04="" EB05="STANDARD" EB06="29" EB07="4225.4" EB08="" EB09="" EB10=""
EB11="" EB12="N" />
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EB11="" EB12="Y" />
EB11="" EB12="N" />
<EB EB01="1" EB02="" EB03.1="1" EB03.2="MH" EB03.3="35" EB03.4="88" EB04="" EB05="STANDARD" />
<EB EB01="B" EB02="IND" EB03.1="33" EB03.2="98" EB04="" EB05="STANDARD" EB06="27" EB07="20" EB08="" EB09=""
EB10="" EB11="" EB12="Y" />
<EB EB01="A" EB02="IND" EB03.1="33" EB03.2="50" EB03.3="52" EB03.4="86" EB03.5="98" EB03.6="BZ" EB03.7="UC"
EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".35" EB09="" EB10="" EB11="" EB12="N">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="33" EB03.2="50" EB03.3="52" EB03.4="86" EB03.5="98" EB03.6="BZ" EB03.7="UC"
EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".35" />
<EB EB01="C" EB02="IND" EB03.1="33" EB03.2="98" EB03.3="BZ" EB03.4="UC" EB04="" EB05="STANDARD" EB06="23"
EB07="0" EB08="" EB09="" EB10="" EB11="" EB12="Y" />
<EB EB01="C" EB02="FAM" EB03.1="33" EB03.2="98" EB03.3="BZ" EB03.4="UC" EB04="" EB05="STANDARD" EB06="23"
EB07="0" EB08="" EB09="" EB10="" EB11="" EB12="Y" />
<EB EB01="F" EB02="" EB03.1="33" EB04="" EB05="STANDARD" EB06="23" EB07="" EB08="" EB09="P6" EB10="1" EB11=""
EB12="W">
<MSG MSG01="SET OF X-RAYS" />
</EB>
<EB EB01="F" EB02="" EB03.1="33" EB04="" EB05="STANDARD" EB06="29" EB07="" EB08="" EB09="P6" EB10="1" EB11=""
EB12="W">
</EB>
<EB EB01="F" EB02="" EB03.1="33" EB04="" EB05="STANDARD" EB06="23" EB07="" EB08="" EB09="VS" EB10="12"
EB11="" EB12="W">
<MSG MSG01="MANIPULATIVE TREATMENT" />
</EB>
<EB EB01="F" EB02="" EB03.1="33" EB04="" EB05="STANDARD" EB06="29" EB07="" EB08="" EB09="VS" EB10="12"
EB11="" EB12="W">
</EB>
<EB EB01="B" EB02="IND" EB03.1="47" EB03.2="51" EB03.3="52" EB03.4="86" EB04="" EB05="STANDARD" EB06="36"
EB07="250" EB08="" EB09="" EB10="" EB11="Y" EB12="Y">
<III III01="ZZ" III02="21" />
</EB>
EB07="350" EB08="" EB09="" EB10="" EB11="Y" EB12="N">
<III III01="ZZ" III02="21" />
</EB>
EB07="350" EB08="" EB09="" EB10="" EB11="Y">
<III III01="ZZ" III02="21" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="47" EB04="" EB05="STANDARD" EB06="36" EB07="" EB08=".35" EB09="" EB10=""
EB11="Y" EB12="N">
<III III01="ZZ" III02="21" />
</EB>
EB11="Y">
<III III01="ZZ" III02="21" />
</EB>
EB11="" EB12="Y">
<III III01="ZZ" III02="22" />
</EB>
EB11="" EB12="N">
<III III01="ZZ" III02="22" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="47" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".35">
<III III01="ZZ" III02="22" />
</EB>
<EB EB01="C" EB02="IND" EB03.1="47" EB03.2="52" EB03.3="86" EB04="" EB05="STANDARD" EB06="23" EB07="0"
EB08="" EB09="" EB10="" EB11="Y" EB12="W">
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<III III01="ZZ" III02="21" />

</EB>
<EB EB01="C" EB02="FAM" EB03.1="47" EB03.2="52" EB03.3="86" EB04="" EB05="STANDARD" EB06="23" EB07="0"
EB08="" EB09="" EB10="" EB11="Y" EB12="W">
<III III01="ZZ" III02="21" />
</EB>
<EB EB01="B" EB02="IND" EB03.1="48" EB04="" EB05="STANDARD" EB06="36" EB07="250" EB08="" EB09="" EB10=""
EB11="Y" EB12="Y" />
EB11="Y" EB12="N">
</EB>
EB11="Y" />
EB11="Y" EB12="N">
</EB>
EB11="Y" />
EB11="Y" EB12="W" />
EB11="Y" EB12="W" />
<EB EB01="A" EB02="IND" EB03.1="50" EB03.2="52" EB03.3="86" EB04="" EB05="STANDARD" EB06="27" EB07=""
EB08=".15" EB09="" EB10="" EB11="" EB12="Y" />
<EB EB01="A" EB02="IND" EB03.1="51" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08="0" EB09="" EB10=""
EB11="" EB12="Y" />
EB11="" EB12="N">
</EB>
<EB EB01="A" EB02="IND" EB03.1="51" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08="0" />
EB11="" EB12="W" />
EB11="" EB12="W" />
<EB EB01="F" EB02="" EB03.1="51" EB04="" EB05="STANDARD" EB06="" EB07="" EB08="" EB09="HS" EB10="72" EB11=""
EB12="W" />
EB11="" EB12="Y">
<III III01="ZZ" III02="23" />
</EB>
EB11="" EB12="N">
<III III01="ZZ" III02="23" />
</EB>
<III III01="ZZ" III02="23" />
</EB>
EB11="" EB12="Y">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
EB11="" EB12="N">
<MSG MSG01="ACCIDENTALINJURY PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08="0">
</EB>
EB11="" EB12="W">
</EB>
EB11="" EB12="W">
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</EB>
<EB EB01="F" EB02="" EB03.1="86" EB04="" EB05="STANDARD" EB06="" EB07="" EB08="" EB09="HS" EB10="72" EB11=""
EB12="W">
</EB>
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III02="23" />
</EB>
EB11="" EB12="N">
<MSG MSG01="MEDICAL EMERGENCY PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III02="23" />
</EB>
<III III01="ZZ" III02="23" />
</EB>
EB11="" EB12="Y">
</EB>
EB11="" EB12="N">
</EB>
</EB>
EB11="" EB12="Y">
<III III01="ZZ" III02="11" />
</EB>
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY SPECIALIST" />
<III III01="ZZ" III02="11" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="" EB07="" EB08=".15" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY OTHER SERVICES" />
<III III01="ZZ" III02="11" />
</EB>
EB11="" EB12="Y">
<III III01="ZZ" III02="11" />
</EB>
EB11="" EB12="Y">
<III III01="ZZ" III02="11" />
</EB>
EB11="" EB12="Y">
<III III01="ZZ" III02="11" />
</EB>
EB11="" EB12="Y">
<III III01="ZZ" III02="11" />
</EB>
EB11="" EB12="Y">
<MSG MSG01="SPECIALIST" />
</EB>
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<EB EB01="B" EB02="IND" EB03.1="BZ" EB04="" EB05="STANDARD" EB06="27" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="Y" />
<EB EB01="B" EB02="IND" EB03.1="UC" EB04="" EB05="STANDARD" EB06="27" EB07="40" EB08="" EB09="" EB10=""
EB11="" EB12="Y" />
</NM1>
</HL>
</HL>
</HL>
<SE SE01="144" SE02="0001" />
</ST>
<GE GE01="1" GE02="1" />
</GS>
<IEA IEA01="1" IEA02="000000001" />
</ISA>
</Interchange>
</EdiTransmission>
EdiXmlExt
This format is identical to the EdiXml format with the addition of English text descriptions of EDI codes. Those English
descriptions are in _TEXT attributes.
Sample Response:
<EdiTransmission>
<Interchange SegmentDelimiter="~" ElementDelimiter="*" SubElementDelimiter=">" RepeatingElementDelimiter="{">
<ISA ISA01="00" ISA01_TEXT="No Authorization Information Present (No Meaningful Information in I02)" ISA02="
" ISA03="00"
ISA03_TEXT="No Security Information Present (No Meaningful Information in I04)" ISA04="
" ISA05="ZZ" ISA05_TEXT="Mutually
Defined" ISA06="MEDDATA
" ISA07="ZZ" ISA07_TEXT="Mutually Defined" ISA08="MEDDATA
" ISA09="130809" ISA10="1219"
ISA11="{" ISA12="00501" ISA12_TEXT="Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003"
ISA13="000000001" ISA14="0" ISA14_TEXT="No Interchange Acknowledgment Requested" ISA15="P" ISA15_TEXT="Production Data"
ISA16=">">
<GS GS01="HB" GS01_TEXT="Eligibility, Coverage or Benefit Information (271)" GS02="MEDDATA" GS03="MEDDATA"
GS04="20130809" GS05="121926" GS06="1" GS07="X" GS07_TEXT="Accredited Standards Committee X12" GS08="005010X279A1">
<ST ST01="271" ST01_TEXT="Eligibility, Coverage or Benefit Information" ST02="0001" ST03="005010X279A1">
<BHT BHT01="0022" BHT01_TEXT="Information Source, Information Receiver, Subscriber, Dependent" BHT02="11"
BHT02_TEXT="Response" BHT03="ABC123" BHT04="20130809" BHT05="131926" />
<HL HL01="1" HL02="" HL03="20" HL03_TEXT="Information Source" HL04="1" HL04_TEXT="Additional Subordinate HL Data
Segment in This Hierarchical Structure.">
<NM1 NM101="PR" NM101_TEXT="Payer" NM102="2" NM102_TEXT="Non-Person Entity" NM103="PAYER NAME" NM104=""
NM105="" NM106="" NM107="" NM108="PI" NM108_TEXT="Payor ID" NM109="ABC123" />
<HL HL01="2" HL02="1" HL03="21" HL03_TEXT="Information Receiver" HL04="1" HL04_TEXT="Additional Subordinate HL Data
Segment in This Hierarchical Structure.">
<NM1 NM101="1P" NM101_TEXT="Provider" NM102="2" NM102_TEXT="Non-Person Entity" NM103="SMITH" NM104=""
NM105="" NM106="" NM107="" NM108="XX" NM108_TEXT="Health Care Financing Administration National Provider Identifier"
NM109="ABC123">
<REF REF01="TJ" REF01_TEXT="Federal Taxpayer's ID" REF02="ABC123" />
</NM1>
<HL HL01="3" HL02="2" HL03="22" HL03_TEXT="Subscriber" HL04="0" HL04_TEXT="No Subordinate HL Segment in This
Hierarchical Structure.">
<TRN TRN01="2" TRN01_TEXT="Referenced Transaction Trace Numbers" TRN02="ABC123" TRN03="9MEDDATACO" />
<NM1 NM101="IL" NM101_TEXT="Insured or Subscriber" NM102="1" NM102_TEXT="Person" NM103="SMITH" NM104="JOHN"
NM105="" NM106="" NM107="" NM108="MI" NM108_TEXT="Member ID" NM109="ABC123">
<REF REF01="6P" REF01_TEXT="Group Number" REF02="ABC123" />
<N3 N301="123 RIDGE WAY" />
<N4 N401="CHARLOTTE" N402="NC" N403="28211" />
<DMG DMG01="D8" DMG01_TEXT="Date Expressed in Format CCYYMMDD" DMG02="19900101" DMG03="M"
DMG03_TEXT="Male" />
<DTP DTP01="291" DTP01_TEXT="Plan" DTP02="RD8" DTP02_TEXT="Range of Dates Expressed in Format CCYYMMDDCCYYMMDD" DTP03="19900101-99991231" />
<EB EB01="1" EB01_TEXT="Active Coverage" EB02="IND" EB02_TEXT="Individual" EB03.1="30" EB03.1_TEXT="Health
Benefit Plan Coverage" EB04="PR" EB04_TEXT="Preferred Provider Organization (PPO)" EB05="STANDARD">
<DTP DTP01="291" DTP01_TEXT="Plan" DTP02="RD8" DTP02_TEXT="Range of Dates Expressed in Format CCYYMMDDCCYYMMDD" DTP03="19900101-99991231" />
</EB>
<EB EB01="P" EB01_TEXT="Benefit Disclaimer">
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<MSG MSG01="UNLESS OTHERWISE REQUIRED BY APPROPRIATE LAW, THIS NOTICE IS NOT A GUARANTEE OF
PAYMENT. BENEFITS ARE SUBJECT TO ALL CONTRACT LIMITATIONS AND THE MEMBER'S ELIGIBILITY STATUS ON THE DATE
OF SERVICE. PAID-TO-DATE AMOUNTS REFLECT ONLY FINALIZED CLAIMS." />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="30" EB03.1_TEXT="Health Benefit Plan
Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" EB07="0" EB08="" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="30" EB03.1_TEXT="Health Benefit Plan
Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" EB07="350" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="30" EB03.1_TEXT="Health Benefit Plan
Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="350" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="30" EB03.1_TEXT="Health Benefit Plan
Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="700" EB08="" EB09=""
</EB>
<EB EB01="G" EB01_TEXT="Out of Pocket (Stop Loss)" EB02="" EB02_TEXT="" EB03.1="30" EB03.1_TEXT="Health Benefit
Plan Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" EB07="2281" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
Plan Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" EB07="4225.4" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No" />
Plan Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="5000" EB08="" EB09=""
Plan Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="7000" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No" />
<EB EB01="1" EB01_TEXT="Active Coverage" EB02="" EB02_TEXT="" EB03.1="1" EB03.1_TEXT="Medical Care" EB03.2="MH"
EB03.2_TEXT="Mental Health" EB03.3="35" EB03.3_TEXT="Dental Care" EB03.4="88" EB03.4_TEXT="Pharmacy" EB04="" EB04_TEXT=""
EB05="STANDARD" />
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="33" EB03.1_TEXT="Chiropractic"
EB03.2="98" EB03.2_TEXT="Professional (Physician) Visit - Office" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27"
EB06_TEXT="Visit" EB07="20" EB08="" EB09="" EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="33" EB03.1_TEXT="Chiropractic"
EB03.2="50" EB03.2_TEXT="Hospital - Outpatient" EB03.3="52" EB03.3_TEXT="Hospital - Emergency Medical" EB03.4="86"
EB03.4_TEXT="Emergency Services" EB03.5="98" EB03.5_TEXT="Professional (Physician) Visit - Office" EB03.6="BZ"
EB03.6_TEXT="Physician Visit - Office: Well" EB03.7="UC" EB03.7_TEXT="Urgent Care" EB04="" EB04_TEXT="" EB05="STANDARD"
EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35" EB09="" EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="N"
EB12_TEXT="No">
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="33" EB03.1_TEXT="Chiropractic"
EB03.2="50" EB03.2_TEXT="Hospital - Outpatient" EB03.3="52" EB03.3_TEXT="Hospital - Emergency Medical" EB03.4="86"
EB03.4_TEXT="Emergency Services" EB03.5="98" EB03.5_TEXT="Professional (Physician) Visit - Office" EB03.6="BZ"
EB03.6_TEXT="Physician Visit - Office: Well" EB03.7="UC" EB03.7_TEXT="Urgent Care" EB04="" EB04_TEXT="" EB05="STANDARD"
EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="33" EB03.1_TEXT="Chiropractic"
EB03.2="98" EB03.2_TEXT="Professional (Physician) Visit - Office" EB03.3="BZ" EB03.3_TEXT="Physician Visit - Office: Well"
EB03.4="UC" EB03.4_TEXT="Urgent Care" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year"
EB07="0" EB08="" EB09="" EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="33" EB03.1_TEXT="Chiropractic"
EB03.2="98" EB03.2_TEXT="Professional (Physician) Visit - Office" EB03.3="BZ" EB03.3_TEXT="Physician Visit - Office: Well"
EB03.4="UC" EB03.4_TEXT="Urgent Care" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year"
EB07="0" EB08="" EB09="" EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="F" EB01_TEXT="Limitations" EB02="" EB02_TEXT="" EB03.1="33" EB03.1_TEXT="Chiropractic" EB04=""
EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="" EB08="" EB09="P6" EB09_TEXT="Number of
Services or Procedures" EB10="1" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
</EB>
EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" EB07="" EB08="" EB09="P6" EB09_TEXT="Number of Services
or Procedures" EB10="1" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
</EB>
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EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="" EB08="" EB09="VS" EB09_TEXT="Visits"
EB10="12" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
</EB>
EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" EB07="" EB08="" EB09="VS" EB09_TEXT="Visits" EB10="12"
EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB03.2="51" EB03.2_TEXT="Hospital - Emergency Accident" EB03.3="52" EB03.3_TEXT="Hospital - Emergency Medical" EB03.4="86"
EB03.4_TEXT="Emergency Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="250"
EB08="" EB09="" EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="Y" EB12_TEXT="Yes">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="21" III02_TEXT="Inpatient Hospital" />
</EB>
EB08="" EB09="" EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="N" EB12_TEXT="No">
</EB>
EB08="" EB09="" EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes">
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="" EB08=".35" EB09="" EB09_TEXT=""
EB10="" EB11="Y" EB11_TEXT="Yes" EB12="N" EB12_TEXT="No">
</EB>
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="" EB08=".35" EB09="" EB09_TEXT=""
EB10="" EB11="Y" EB11_TEXT="Yes">
</EB>
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09="" EB09_TEXT="" EB10=""
EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="22" III02_TEXT="Outpatient Hospital" />
</EB>
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35" EB09="" EB09_TEXT="" EB10=""
EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No">
</EB>
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35">
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB03.2="52" EB03.2_TEXT="Hospital - Emergency Medical" EB03.3="86" EB03.3_TEXT="Emergency Services" EB04="" EB04_TEXT=""
EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09="" EB09_TEXT="" EB10="" EB11="Y"
EB11_TEXT="Yes" EB12="W" EB12_TEXT="Not Applicable">
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="47" EB03.1_TEXT="Hospital"
EB03.2="52" EB03.2_TEXT="Hospital - Emergency Medical" EB03.3="86" EB03.3_TEXT="Emergency Services" EB04="" EB04_TEXT=""
EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09="" EB09_TEXT="" EB10="" EB11="Y"
EB11_TEXT="Yes" EB12="W" EB12_TEXT="Not Applicable">
</EB>
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<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital Inpatient" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="250" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="Y" EB12_TEXT="Yes" />
EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="N" EB12_TEXT="No">
</EB>
EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" />
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital Inpatient" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="" EB08=".35" EB09=""
EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="N" EB12_TEXT="No">
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital Inpatient" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="" EB08=".35" EB09=""
EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital Inpatient" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="48" EB03.1_TEXT="Hospital - Inpatient"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09="" EB09_TEXT=""
EB10="" EB11="Y" EB11_TEXT="Yes" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="50" EB03.1_TEXT="Hospital Outpatient" EB03.2="52" EB03.2_TEXT="Hospital - Emergency Medical" EB03.3="86" EB03.3_TEXT="Emergency Services" EB04=""
EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09="" EB09_TEXT="" EB10="" EB11=""
EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="51" EB03.1_TEXT="Hospital Emergency Accident" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0" EB09=""
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="51" EB03.1_TEXT="Hospital Emergency Accident" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No">
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="51" EB03.1_TEXT="Hospital Emergency Accident" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="51" EB03.1_TEXT="Hospital Emergency Accident" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09=""
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="51" EB03.1_TEXT="Hospital - Emergency
Accident" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09=""
<EB EB01="F" EB01_TEXT="Limitations" EB02="" EB02_TEXT="" EB03.1="51" EB03.1_TEXT="Hospital - Emergency Accident"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="" EB06_TEXT="" EB07="" EB08="" EB09="HS" EB09_TEXT="Hours" EB10="72"
EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="52" EB03.1_TEXT="Hospital Emergency Medical" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="23" III02_TEXT="Emergency Room - Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="52" EB03.1_TEXT="Hospital Emergency Medical" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No">
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="52" EB03.1_TEXT="Hospital Emergency Medical" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15">
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
</EB>
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Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No">
<MSG MSG01="ACCIDENTALINJURY PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0">
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09=""
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="86" EB03.1_TEXT="Emergency Services"
EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
</EB>
<EB EB01="F" EB01_TEXT="Limitations" EB02="" EB02_TEXT="" EB03.1="86" EB03.1_TEXT="Emergency Services" EB04=""
EB04_TEXT="" EB05="STANDARD" EB06="" EB06_TEXT="" EB07="" EB08="" EB09="HS" EB09_TEXT="Hours" EB10="72" EB11=""
EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
</EB>
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09="" EB09_TEXT=""
</EB>
</EB>
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15">
</EB>
</EB>
</EB>
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35">
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="20" EB08="" EB09="" EB09_TEXT=""
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="11" III02_TEXT="Office" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="30" EB08="" EB09="" EB09_TEXT=""
</EB>
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Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="" EB06_TEXT="" EB07="" EB08=".15" EB09="" EB09_TEXT="" EB10=""
EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="MEDICAL EMERGENCY OTHER SERVICES" />
</EB>
</EB>
</EB>
</EB>
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="98" EB03.1_TEXT="Professional
(Physician) Visit - Office" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="30" EB08="" EB09=""
<MSG MSG01="SPECIALIST" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="BZ" EB03.1_TEXT="Physician Visit Office: Well" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="0" EB08="" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="UC" EB03.1_TEXT="Urgent Care"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="40" EB08="" EB09="" EB09_TEXT="" EB10=""
EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
</NM1>
</HL>
</HL>
</HL>
<SE SE01="144" SE02="0001" />
</ST>
<GE GE01="1" GE02="1" />
</GS>
<IEA IEA01="1" IEA02="000000001" />
</ISA>
</Interchange>
</EdiTransmission>
EdiXmlExtHtml
Xml Schema of Response:
<EdiXmlExtHtml>
<EdiTransmission></EdiTransmission>
<html></html>
<ResponseResult></ResponseResult>
</EdiXmlExtHtml>
EdiTransmission - element contains what would be returned in an EdiXmlExt response

html - contains the html markup
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The html markup utilizes a cascading style sheet which can be obtained upon request from the Exchange
EDI Insurance Eligibility support team.
o The contents of the html element are encoded as the value of the html element.
ResponseResult - an integer value that defines type of response, Eligible, Inactive, etc.
o This element is only populated on a single inquiry, not batch.
Response Result Eligibility values:
Response Result Description

0 Unknown
1 Eligible
2 Inactive
3 Not found
4 Payer Not Responding
5 Provider Validation
6 Other Eligible
7 Validation Error
10 Insufficient Application Data
11 997
12 TA1
15 Invalid Request
VerboseXml
VerboseXml is a custom Exchange EDI xml representation of an EDI transmission. EDI codes are replaced with English
descriptions and element names are descriptive. All data is contained in xml elements. An xml schema for the response
can be provided upon request.
<TransactionResponse>
<RequestorTrackingID>ABC123</RequestorTrackingID>
<ResponseResult>1</ResponseResult>
<InterchangeControlHeader>
<AuthorInfoQualifier>00</AuthorInfoQualifier>
<SecurityInfoQual>00</SecurityInfoQual>
<InterchangeSenderIDQual>ZZ</InterchangeSenderIDQual>
<InterchangeSenderID>MEDDATA </InterchangeSenderID>
<InterchangeReceiverIDQual>ZZ</InterchangeReceiverIDQual>
<InterchangeReceiverID>MEDDATA </InterchangeReceiverID>
<InterchangeDate>080821</InterchangeDate>
<InterchangeTime>0936</InterchangeTime>
<InterCtrlStandIdent>U</InterCtrlStandIdent>
<InterCtrlVersionNum>00401</InterCtrlVersionNum>
<InterCtrlNumber>065451189</InterCtrlNumber>
<AckRequested>0</AckRequested>
<UsageIndicator>P</UsageIndicator>
<ComponentElemSeparator>.</ComponentElemSeparator>
</InterchangeControlHeader>
<FunctionalGroupHeader>
<FunctionalIDCode>HB</FunctionalIDCode>
<ApplicationSenderCode>MEDDATA</ApplicationSenderCode>
<ApplicationReceiverCode>MEDDATA</ApplicationReceiverCode>
<Date>20080821</Date>
<Time>09364209</Time>
<GroupCtrlNumber>1</GroupCtrlNumber>
<ResponsibleAgencyCode>X</ResponsibleAgencyCode>
<VerReleaseIDCode>005010X279A1</VerReleaseIDCode>
</FunctionalGroupHeader>
<TransactionSetHeader>
<TSIDCode>271</TSIDCode>
<TSControlNumber>0001</TSControlNumber>
<ImplConventionReference>005010X279A1</ImplConventionReference>
</TransactionSetHeader>
<BeginningOfHierarchicalTransaction>
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<HierarchStructCode>0022</HierarchStructCode>
<TSPurposeCode>11</TSPurposeCode>
<ReferenceIdent>ABC123</ReferenceIdent>
<Date>20080821</Date>
<Time>09364209</Time>
</BeginningOfHierarchicalTransaction>
<InformationSourceLevelLoop>
<InformationSourceLevel>
<HierarchIDNumber>1</HierarchIDNumber>
<HierarchLevelCode>20</HierarchLevelCode>
<HierarchChildCode>1</HierarchChildCode>
</InformationSourceLevel>
<InformationSourceNameLoop>
<InformationSourceName>
<EntityIDCode>Payer</EntityIDCode>
<EntityTypeQualifier>Non-Person Entity</EntityTypeQualifier>
<NameLastOrgName>AETNA INC</NameLastOrgName>
<IDCodeQualifier>Payor Identification</IDCodeQualifier>
<IDCode>ABC123</IDCode>
</InformationSourceName>
</InformationSourceNameLoop>
</InformationSourceLevelLoop>
<InformationReceiverLevelLoop>
<InformationReceiverLevel>
<HierarchParentID>1</HierarchParentID>
</InformationReceiverLevel>
<InformationReceiverNameLoop>
<InformationReceiverName>
<EntityIDCode>Provider</EntityIDCode>
<NameLastOrgName>SMITH</NameLastOrgName>
<IDCodeQualifier>Health Care Financing Administration National Provider Identifier</IDCodeQualifier>
</InformationReceiverName>
</InformationReceiverNameLoop>
</InformationReceiverLevelLoop>
<SubscriberLevelLoop>
<SubscriberLevel>
<HierarchParentID>2</HierarchParentID>
</SubscriberLevel>
<SubscriberNameLoop>
<SubscriberName>
<EntityIDCode>Insured or Subscriber</EntityIDCode>
<EntityTypeQualifier>Person</EntityTypeQualifier>
<NameFirst>JOHN</NameFirst>
<NameMiddle>S</NameMiddle>
<IDCodeQualifier>Member Identification Number</IDCodeQualifier>
</SubscriberName>
<SubscriberAdditionalIdentification>
<ReferenceIdentQual>Group Number</ReferenceIdentQual>
<Description>ABC</Description>
</SubscriberAdditionalIdentification>
<SubscriberAdditionalIdentification>
<ReferenceIdentQual>Plan Number</ReferenceIdentQual>
<Description>ABC</Description>
</SubscriberAdditionalIdentification>
<SubscriberAddress>
<AddressInformation>123 RIDGE WAY</AddressInformation>
</SubscriberAddress>
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<SubscriberCityStateZipCode>
<CityName>CHARLOTTE</CityName>
<StateOrProvCode>NC</StateOrProvCode>
<PostalCode>28211</PostalCode>
</SubscriberCityStateZipCode>
<SubscriberDemographicInformation>
<DateTimeFormatQual>D8</DateTimeFormatQual>
<DateTimePeriod>19900101</DateTimePeriod>
<GenderCode>Male</GenderCode>
</SubscriberDemographicInformation>
<SubscriberRelationship>
<YesNoCondRespCode>Yes</YesNoCondRespCode>
<IndividualRelatCode>Self</IndividualRelatCode>
<MaintenanceTypeCode>Change</MaintenanceTypeCode>
<MaintainReasonCode>Change in Identifying Data Elements</MaintainReasonCode>
</SubscriberRelationship>
<SubscriberDate>
<DateTimeQualifier>Eligibility</DateTimeQualifier>
</SubscriberDate>
<SubscriberDate>
<DateTimeQualifier>Service</DateTimeQualifier>
<DateTimeFormatQual>RD8</DateTimeFormatQual>
<DateTimePeriod>19900101-99991231</DateTimePeriod>
</SubscriberDate>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Primary Care Provider</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Health Benefit Plan Coverage</ServiceTypeCode>
<InsuranceTypeCode>Point of Service (POS)</InsuranceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberEligibilityBenefitDate>
<DateTimeQualifier>Period Start</DateTimeQualifier>
</SubscriberEligibilityBenefitDate>
<SubscriberBenefitRelatedEntityNameLoop>
<SubscriberBenefitRelatedEntityName>
<EntityIDCode>Primary Care Provider</EntityIDCode>
<EntityTypeQualifier>Person</EntityTypeQualifier>
<NameFirst>JOHN</NameFirst>
<NameMiddle>S</NameMiddle>
</SubscriberBenefitRelatedEntityName>
</SubscriberBenefitRelatedEntityNameLoop>
</SubscriberEligibilityOrBenefitInformationLoop>
<EligibilityBenefitInf>Primary Care Provider</EligibilityBenefitInf>
<EntityIDCode>Gateway Provider</EntityIDCode>
<EligibilityBenefitInf>Other Source of Data</EligibilityBenefitInf>
<EntityIDCode>Facility</EntityIDCode>
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<IDCodeQualifier>Facility Identification</IDCodeQualifier>
<EligibilityBenefitInf>Active Coverage</EligibilityBenefitInf>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
<SubscriberMessageText>
<FreeFormMessageTxt>Plan Requires PreCert</FreeFormMessageTxt>
</SubscriberMessageText>
<EligibilityBenefitInf>Benefit Description</EligibilityBenefitInf>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<MonetaryAmount>500</MonetaryAmount>
<TimePeriodQualifier>Remaining</TimePeriodQualifier>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<FreeFormMessageTxt>UNLIMITED</FreeFormMessageTxt>
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<Percent>0</Percent>
<FreeFormMessageTxt>CHIRO VST/EVAL</FreeFormMessageTxt>
<FreeFormMessageTxt>MANPULATN CHRO</FreeFormMessageTxt>
<EligibilityBenefitInf>Co-Payment</EligibilityBenefitInf>
<FreeFormMessageTxt>CHIRO VST/EVAL</FreeFormMessageTxt>
<FreeFormMessageTxt>MANPULATN CHRO</FreeFormMessageTxt>
<FreeFormMessageTxt>CHIRO VST/EVAL/DED WAIVED</FreeFormMessageTxt>
<FreeFormMessageTxt>MANPULATN CHRO/DED WAIVED</FreeFormMessageTxt>
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<FreeFormMessageTxt>Plan includes NAP</FreeFormMessageTxt>
<FreeFormMessageTxt>Unlimited Lifetime Benefits</FreeFormMessageTxt>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
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<FreeFormMessageTxt>RM & BOARD</FreeFormMessageTxt>
<AuthorizationIndicator>Yes</AuthorizationIndicator>
<FreeFormMessageTxt>RM & BOARD</FreeFormMessageTxt>
<FreeFormMessageTxt>RM & BOARD /DED WAIVED</FreeFormMessageTxt>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
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<FreeFormMessageTxt>OP HOSPITAL</FreeFormMessageTxt>
<FreeFormMessageTxt>OP SURG FAC</FreeFormMessageTxt>
<CoverageLevelCode>Individual</CoverageLevelCode>
<SubscriberHealthCareServicesDelivery>
<QuantityQualifier>Visits</QuantityQualifier>
<Quantity>30</Quantity>
<UnitBasisMeasCode>Years</UnitBasisMeasCode>
<SampleSelModulus>1</SampleSelModulus>
</SubscriberHealthCareServicesDelivery>
<FreeFormMessageTxt>CHIRO</FreeFormMessageTxt>
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<ServiceTypeCode>Emergency Services</ServiceTypeCode>
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<FreeFormMessageTxt>ER PHYSICIAN</FreeFormMessageTxt>
<FreeFormMessageTxt>ER FACILITY</FreeFormMessageTxt>
<FreeFormMessageTxt>URGENT CARE</FreeFormMessageTxt>
<FreeFormMessageTxt>ER FACILITY</FreeFormMessageTxt>
<FreeFormMessageTxt>URGENT CARE</FreeFormMessageTxt>
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<FreeFormMessageTxt>ER PHYSICIAN /DED WAIVED</FreeFormMessageTxt>
<FreeFormMessageTxt>ER FACILITY /DED WAIVED</FreeFormMessageTxt>
<FreeFormMessageTxt>URGENT CARE /DED WAIVED</FreeFormMessageTxt>
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<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
<FreeFormMessageTxt>SPEC OFF VST</FreeFormMessageTxt>
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<FreeFormMessageTxt>PHYS OFFICE VS</FreeFormMessageTxt>
<FreeFormMessageTxt>SPEC OFF VST</FreeFormMessageTxt>
<FreeFormMessageTxt>PHYS OFFICE VS</FreeFormMessageTxt>
<FreeFormMessageTxt>SPEC OFF VST /DED WAIVED</FreeFormMessageTxt>
<FreeFormMessageTxt>PHYS OFFICE VS/DED WAIVED</FreeFormMessageTxt>
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</SubscriberNameLoop>
</SubscriberLevelLoop>
<FunctionalGroupTrailer>
<FunctionalIDCode>1</FunctionalIDCode>
<NumberOfInclTS>1</NumberOfInclTS>
</FunctionalGroupTrailer>
<InterchangeControlTrailer>
<NumberOfInclGS>1</NumberOfInclGS>
<InterCtrlNumber>065451189</InterCtrlNumber>
</InterchangeControlTrailer>
</TransactionResponse>
Example Requests
Examples are shown using EDI as the request and response formats. For security purposes the EDI has been replaced with
a placeholder.
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SubmitSync SOAP (Version 1.2)

<soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:sub="http://services.medconnect.net/submissionportal">
<soap:Header>
<sub:SecurityHeader>
<sub:UserName>username</sub:UserName>
<sub:Password>password</sub:Password>
</sub:SecurityHeader>
</soap:Header>
<soap:Body>
<sub:SubmitSync>
<sub:request>ISA*...place X12 here...IEA</sub:request>
<sub:requestFormat>EDI</sub:requestFormat>
<sub:responseFormat>EDI</sub:responseFormat>
<sub:synchronousTimeout>00:01:00</sub:synchronousTimeout>
<sub:submissionTimeout>00:01:00</sub:submissionTimeout>
</sub:SubmitSync>
</soap:Body>
</soap:Envelope>
Response:
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema">
<soap:Body>
<SubmitSyncResponse xmlns="http://services.medconnect.net/submissionportal">
<SubmitSyncResult>ISA...IEA...~<SubmitSyncResult>
</SubmitSyncResponse>
</soap:Body>
</soap:Envelope>
SubmitASync SOAP (Version 1.2)

<soap:Header>
</soap:Header>
<soap:Body>
<sub:SubmitASync>
<sub:request>ISA*...place X12 here...IEA</sub:request>
<sub:submissionTimeout>1.00:00:00</sub:submissionTimeout>
</sub:SubmitASync>
</soap:Body>
</soap:Envelope>
Response:
<soap:Body>
<SubmitASyncResponse xmlns="http://services.medconnect.net/submissionportal">
<SubmitASyncResult>665a3d9c-0000-0000-0000-f2d949f90f70</SubmitASyncResult>
</SubmitASyncResponse>
</soap:Body>
</soap:Envelope>
GetResponses SOAP (Version 1.2)

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<soap:Header>
</soap:Header>
<soap:Body>
<sub:GetResponses>
</sub:GetResponses>
</soap:Body>
</soap:Envelope>
Response:
<soap:Body>
<GetResponsesResponse xmlns="http://services.medconnect.net/submissionportal">
<GetResponsesResult>ISA...IEA...~</GetResponsesResult>
</GetResponsesResponse>
</soap:Body>
</soap:Envelope>
GetResponsesBySubmissionId SOAP (Version 1.2)

<soap:Header>
</soap:Header>
<soap:Body>
<sub:GetResponsesBySubmissionId>
<sub:submissionId>665a3d9c-0000-0000-0000-f2d949f90f70</sub:submissionId>
<sub:overrideSent>0</sub:overrideSent>
</sub:GetResponsesBySubmissionId>
</soap:Body>
</soap:Envelope>
Response:
<soap:Body>
<GetResponsesBySubmissionIdResponse xmlns="http://services.medconnect.net/submissionportal">
<GetResponsesBySubmissionIdResult>ISA...IEA...~</GetResponsesBySubmissionIdResult>
</GetResponsesBySubmissionIdResponse>
</soap:Body>
</soap:Envelope>
HTTP Message
Full HTTP message example:
POST https://services.medconnect.net/submissionportal/submissionportal.asmx HTTP/1.1
Content-Type: application/soap+xml;charset=UTF8;action="http://services.medconnect.net/submissionportal/SubmitSync"
User-Agent: Jakarta Commons-HttpClient/3.1
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Host: services.medconnect.net
Content-Length: 888
<soap:Header>
</soap:Header>
<soap:Body>
<sub:SubmitSync>
<sub:request> ISA...IEA...~</sub:request>
<sub:synchronousTimeout>01:01:00</sub:synchronousTimeout>
<sub:submissionTimeout>01:01:00</sub:submissionTimeout>
</sub:SubmitSync>
</soap:Body>
</soap:Envelope>
URL Get / Post

https://services.meddatahealth.com/clients/default/submit.aspx?userId=username&userPwd=password&requestType
=EDI&responseType=EDI&timeout=00:01:00&request=ISA...IEA&requestTime=12301000&requestDate=20090101
Full HTTP GET message example:

GET
/clients/default/submit.aspx?userId=username&userPwd=password&requestType=EDI&responseType=EDI&timeout=00:01:00&request=IS
AIEA~&requestTime=12301000&requestDate=20090101 HTTP/1.1
Accept: image/jpeg, application/x-ms-application, image/gif, application/xaml+xml, image/pjpeg, application/x-ms-xbap,
application/msword, application/vnd.ms-excel, application/vnd.ms-powerpoint, application/x-silverlight, application/xsilverlight2-b2, application/x-shockwave-flash, application/vnd.ms-xpsdocument, */*
Accept-Language: en-US
User-Agent: Mozilla/4.0 (compatible; MSIE 8.0; Windows NT 6.1; Trident/4.0; SLCC2; .NET CLR 2.0.50727; .NET CLR 3.5.30729;
.NET CLR 3.0.30729; Media Center PC 6.0; .NET CLR 1.1.4322; .NET CLR 3.5.20404; .NET CLR 3.5.21022;
OfficeLiveConnector.1.3; OfficeLivePatch.0.0; SLCC1)
Accept-Encoding: gzip, deflate
Host: localhost:10000
Sample Code
The sample code provided was created using Visual Studio .NET 2008 in the VB.NET language.
Add a new Service Reference (name is portal) using the URL:
https://services.medconnect.net/submissionportal/submissionportal.asmx
Code:
Dim portal As New portal.MedDataExternalSubmissionPortalSoapClient()
Dim securityHdr As New portal.SecurityHeader() With {.UserName = "UserName", .Password = "Password"}
Dim responseEdi As String = String.Empty
responseEdi = portal.SubmitSync(securityHdr, _
"ISA...", _
"EDI", _
"EDI", _
"00:01:00", _
"00:01:00")
Debug.Print(responseEdi)
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Appendix D: Change Summary

Date
Changes
03/21/2014
Added Payer Evercare 10807
03/21/2014
Added Payer Care Improvement Plus 10806
03/21/2014
Added Payer Health Plan of Nevada 10804
03/21/2014
Added Payer Blue Administrators of Mass 10803
03/20/2014
Added Payer Aetna 10004
03/20/2014
Added Payers BCBS Michigan Instituational 10519 and Professional 10038
03/20/2014
Added Payer BCBS North Carolina 10383
03/20/2014
Added Payer: BCBS of New York (Excellus) 10323
03/20/2014
Added Payer: BCBS of Colorado (Wellpoint Anthem) 10029
03/20/2014
Added Payer: BCBS of Connecticut (Wellpoint Anthem) 10030
03/20/2014
Added Payer: BCBS of Indiana (Wellpoint Anthem) 10258
03/20/2014
Added Payer: BCBS of Kentucky (Wellpoint Anthem) 10259
03/20/2014
Added Payer: BCBS of Maine (Wellpoint Anthem) 10036
03/20/2014
Added Payer: BCBS of Missouri (Wellpoint Anthem) 10322
03/20/2014
Added Payer: BCBS of Nevada (Wellpoint Anthem) 10260
03/20/2014
Added Payer: BCBS of New Hampshire (Wellpoint Anthem) 10261
03/20/2014
Added Payer: BCBS of Ohio (Wellpoint Anthem) 10044
03/20/2014
Added Payer: BCBS of Virginia (Wellpoint Anthem) 10049
03/20/2014
Added Payer: BCBS of Wisconsin (Wellpoint Anthem) 10299
03/20/2014
Added Payer: Blue Cross of California 10051
03/20/2014
Added Payer: BCBS of Georgia 10032
03/20/2014
Added Payer: BCBS of Alabama 10025
03/20/2014
Added Payer: BCBS of Alabama (Institutional) 10609
03/20/2014
Added Payer: United Healthcare 10002
03/20/2014
Added Payer: BCBS of South Carolina 10047
03/20/2014
Added Payer: BCBS of Arizona 10027
03/20/2014
Added Payer: BCBS of Arkansas 10028
03/20/2014
Added Payer: BCBS of Kansas City 10473
03/20/2014
Added Payer: BCBS of Kansas 10034
03/20/2014
Added Payer: BCBS of New York (Excellus) 10323
03/20/2014
Added Payer: BCBS of New York (Empire) 10043
03/20/2014
Added Payer: BCBS of Utica-Watertown (NY) 10470
03/20/2014
Added Payer: BCBS of the Rochester Area (NY) 10469
03/20/2014
Added Payer:BCBS of Central New York 10461
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03/20/2014
Added Payer: Cigna 10062
03/20/2014
Added New Payer: United Concordia Federal Employees Program - Dental 10809
03/20/2014
Added New Payer: United Concordia Companies, Inc. - Dental 10810
03/20/2014
Added New Payer: Florida Combined Life - Dental - 10811
3/12/2014
Added New Payer: DeCare Dental Health Insurance - 10780
3/12/2014
Added New Payer: Group Health Cooperative of South Central Wisconsin - Dental - 10781
3/12/2014
Added New Payer: Patriot Dental - 10782
3/12/2014
Added New Payer: Brokers National - Dental - 10783
3/12/2014
Added New Payer: Employee Benefit Services - Dental - 10784
3/12/2014
Added New Payer: Hawaii Medical Assurance Association - Dental - 10785
3/12/2014
Added New Payer: Altus Dental - 10786
3/12/2014
Added New Payer: Dental Benefit Providers - 10787
3/12/2014
Added New Payer: Guardian Life Insurance Co. of America - Dental - 10788
3/12/2014
Added New Payer: Healthsource Provident - Dental - 10789
3/12/2014
Added New Payer: Provident Preferred Network - Dental - 10790
3/12/2014
Added New Payer: UNICARE - Dental - 10791
3/12/2014
Added New Payer: Securian Dental - 10792
3/12/2014
Added New Payer: Securian/Patriot Dental - 10793
3/12/2014
Added New Payer: TennDent - 10794
3/12/2014
Added New Payer: Hershey Healthsmile - Dental - 10795
3/12/2014
Added New Payer: Zenith Administrators (MN) - Dental - 10796
3/12/2014
Added New Payer: Wilson McShane - Dental - 10797
3/12/2014
Added New Payer: Alan Sturm and Associates - Dental - 10798
3/12/2014
Added New Payer: Flex Compensation - Dental - 10799
2/28/2014
Added Payers MetLife Dental Payer ID 10134 and AFLAC Dental payer ID 10398
2/28/2014
Added New Payer: Delta Dental Ins. Co. - Alabama - 10709
2/28/2014
Added New Payer: Delta Dental Ins. Co. - Florida - 10710
2/28/2014
Added New Payer: Delta Dental Ins. Co. - Georgia - 10711
2/28/2014
Added New Payer: Delta Dental Ins. Co. - Louisiana - 10712
2/28/2014
Added New Payer: Delta Dental Ins. Co. - Mississippi - 10713
2/28/2014
Added New Payer: Delta Dental Ins. Co. - Montana - 10714
2/28/2014
Added New Payer: Delta Dental Ins. Co. - Nevada - 10715
2/28/2014
Added New Payer: Delta Dental Ins. Co. - Texas - 10716
2/28/2014
Added New Payer: Delta Dental Ins. Co. - Utah - 10717
2/28/2014
Added New Payer: Delta Dental of California - 10705
2/28/2014
Added New Payer: Delta Dental of Colorado - 10718
2/28/2014
Added New Payer: Delta Dental of Connecticut - 10719
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2/28/2014
Added New Payer: Delta Dental of Delaware - 10720
2/28/2014
Added New Payer: Delta Dental of Hawaii - 10721
2/28/2014
Added New Payer: Delta Dental of Indiana - 10722
2/28/2014
Added New Payer: Delta Dental of Maryland - 10723
2/28/2014
Added New Payer: Delta Dental of Michigan - 10724
2/28/2014
Added New Payer: Delta Dental of Minnesota - 10725
2/28/2014
Added New Payer: Delta Dental of Nebraska - 10726
2/28/2014
Added New Payer: Delta Dental of New Jersey - 10727
2/28/2014
Added New Payer: Delta Dental of New Mexico - 10728
2/28/2014
Added New Payer: Delta Dental of New York - 10729
2/28/2014
Added New Payer: Delta Dental of North Carolina - 10730
2/28/2014
Added New Payer: Delta Dental of North Dakota - 10731
2/28/2014
Added New Payer: Delta Dental of Ohio - 10732
2/28/2014
Added New Payer: Delta Dental of Pennsylvania - 10733
2/28/2014
Added New Payer: Delta Dental of Rhode Island - 10734
2/28/2014
Added New Payer: Delta Dental of Tennessee - 10735
2/28/2014
Added New Payer: Delta Dental of Virginia - 10736
2/28/2014
Added New Payer: Delta Dental of Washington DC - 10737
2/28/2014
Added New Payer: Delta Dental of Washington State - 10738
2/28/2014
Added New Payer: Delta Dental of West Virginia - 10739
2/28/2014
Added New Payer: DeltaCare USA - Claims - 10740
2/28/2014
Added New Payer: DeltaCare USA - Encounters - 10741
02/25/2014
Created Dental Payer Companion Guide
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Eligibility (270/271) Dental Payers Companion Guide

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Eligibility (270/271) Dental Payers Companion Guide

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Eligibility (270/271)

Dental Payers Companion Guide

2013 Exchange EDI, LLC.

GETTING STARTED WITH EXCHANGE EDI ...................................................................................................................... 9

CONNECTIVITY WITH THE PAYER .................................................................................................................................. 10

CONTACT INFORMATION ................................................................................................................................................ 16

CONTROL SEGMENTS AND ENVELOPES ......................................................................................................................... 17

PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ................................................................................................. 19

BCBS of New Hampshire (Wellpoint Anthem) 10261 ................................................................................................................ 62

APPENDIX A: SPECIAL ENROLLMENT PAYERS............................................................................................................ 125

Getting Started with Exchange EDI

Certification and Testing Overview

Connectivity with the Payer

Transmission Administrative Procedures

Communication Protocol Specifications

Web Services (XML SOAP) Submission Portal

Web Service Description

Questions regarding 270/271 transactions

Exchange EDI Enrollment and Customer Support

Web portal related questions

Control Segments and Envelopes

Codes and Values

N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code

Payer Specific Business Rules and Limitations

Loop 2000A: Information Source Payer Level.

Loop 2000B: Information Receiver Provider Level

Loop 2000C: Subscriber Level

Loop 2000D: Dependent Level

Transaction Specific Information

Dep: Date of Birth

Dep: Date of Birth

Dep: Date of Birth

Sub: Last Name

Sub: First Name

Dep: Last Name

Dep: Last Name

Dep: First Name

Dep: Date of Birth

Dep: First Name

Dep: Date of Birth

Reference Element Name

Identification Code Qualifier

Name Last or Organization Name

Exchange EDI Payer ID

Information Receiver ID Qualifier

Search options: #5 and #9

Search options: #5 and #9

Information Receiver ID Qualifier

Member ID (CUMB ID)

Identification Code Qualifier

Note: CUMB ID is for Non-HMO

Information Receiver ID Qualifier

Reference Identification Qualifier

Reference Identification Qualifier

Search options: #3 and #7

Note: HMO Subscriber ID is

Search options: #4 and #8

No Future Dates allowed.

Service Type Code

Search options: #9 and #10

Search options: #9 and #10

Reference Identification Qualifier

Search options:#6, #7, #8, #9, #10