Segment
X12 EDI Release 00504
To specify inquired eligibility or benefit information
Elements
Code identifying the classification of service
Codes (191)- 1Medical Care
- 2Surgical
- 3Consultation
- 4Diagnostic X-Ray
- 5Diagnostic Lab
- 6Radiation Therapy
- 7Anesthesia
- 8Surgical Assistance
- 9Other Medical
- 10Blood Charges
- 11Used Durable Medical Equipment
- 12Durable Medical Equipment Purchase
- 13Ambulatory Service Center Facility
- 14Renal Supplies in the Home
- 15Alternate Method Dialysis
- 16Chronic Renal Disease (CRD) Equipment
- 17Pre-Admission Testing
- 18Durable Medical Equipment Rental
- 19Pneumonia Vaccine
- 20Second Surgical Opinion
- 21Third Surgical Opinion
- 22Social Work
- 23Diagnostic Dental
- 24Periodontics
- 25Restorative
- 26Endodontics
- 27Maxillofacial Prosthetics
- 28Adjunctive Dental Services
- 30Health Benefit Plan Coverage
- 31Benefit Disclaimer
- 32Plan Waiting Period
- 33Chiropractic
- 34Chiropractic Office Visits
- 35Dental Care
- 36Dental Crowns
- 37Dental Accident
- 38Orthodontics
- 39Prosthodontics
- 40Oral Surgery
- 41Routine (Preventive) Dental
- 42Home Health Care
- 43Home Health Prescriptions
- 44Home Health Visits
- 45Hospice
- 46Respite Care
- 47Hospital
- 48Hospital - Inpatient
- 49Hospital - Room and Board
- 50Hospital - Outpatient
- 51Hospital - Emergency Accident
- 52Hospital - Emergency Medical
- 53Hospital - Ambulatory Surgical
- 54Long Term Care
- 55Major Medical
- 56Medically Related Transportation
- 57Air Transportation
- 58Cabulance
- 59Licensed Ambulance
- 60General Benefits
- 61In-vitro Fertilization
- 62MRI/CAT Scan
- 63Donor Procedures
- 64Acupuncture
- 65Newborn Care
- 66Pathology
- 67Smoking Cessation
- 68Well Baby Care
- 69Maternity
- 70Transplants
- 71Audiology Exam
- 72Inhalation Therapy
- 73Diagnostic Medical
- 74Private Duty Nursing
- 75Prosthetic Device
- 76Dialysis
- 77Otological Exam
- 78Chemotherapy
- 79Allergy Testing
- 80Immunizations
- 81Routine Physical
- 82Family Planning
- 83Infertility
- 84Abortion
- 85AIDS
- 86Emergency Services
- 87Cancer
- 88Pharmacy
- 89Free Standing Prescription Drug
- 90Mail Order Prescription Drug
- 91Brand Name Prescription Drug
- 92Generic Prescription Drug
- 93Podiatry
- 94Podiatry - Office Visits
- 95Podiatry - Nursing Home Visits
- 96Professional (Physician)
- 97Anesthesiologist
- 98Professional (Physician) Visit - Office
- 99Professional (Physician) Visit - Inpatient
- BNon-escrow or Non-impound Service
- CEscrow or Impound Service
- A0Professional (Physician) Visit - Outpatient
- A1Professional (Physician) Visit - Nursing Home
- A2Professional (Physician) Visit - Skilled Nursing Facility
- A3Professional (Physician) Visit - Home
- A4Psychiatric
- A5Psychiatric - Room and Board
- A6Psychotherapy
- A7Psychiatric - Inpatient
- A8Psychiatric - Outpatient
- A9Rehabilitation
- AARehabilitation - Room and Board
- ABRehabilitation - Inpatient
- ACRehabilitation - Outpatient
- ADOccupational Therapy
- AEPhysical Medicine
- AFSpeech Therapy
- AGSkilled Nursing Care
- AHSkilled Nursing Care - Room and Board
- AISubstance Abuse
- AJAlcoholism
- AKDrug Addiction
- ALVision (Optometry)
- AMFrames
- ANRoutine Exam
- AOLenses
- APRoutine Eye Exam
- AQNonmedically Necessary Physical
- ARExperimental Drug Therapy
- B1Burn Care
- B2Brand Name Prescription Drug - Formulary
- B3Brand Name Prescription Drug - Non-Formulary
- BAIndependent Medical Evaluation
- BBPartial Hospitalization (Psychiatric)
- BCDay Care (Psychiatric)
- BDCognitive Therapy
- BEMassage Therapy
- BFPulmonary Rehabilitation
- BGCardiac Rehabilitation
- BHPediatric
- BINursery
- BJSkin
- BKOrthopedic
- BLCardiac
- BMLymphatic
- BNGastrointestinal
- BPEndocrine
- BQNeurology
- BREye
- BSInvasive Procedures
- BTGynecological
- BUObstetrical
- BVObstetrical/Gynecological
- BWMail Order Prescription Drug: Brand Name
- BXMail Order Prescription Drug: Generic
- BYPhysician Visit - Office: Sick
- BZPhysician Visit - Office: Well
- C1Coronary Care
- CAPrivate Duty Nursing - Inpatient
- CBPrivate Duty Nursing - Home
- CCSurgical Benefits - Professional (Physician)
- CDSurgical Benefits - Facility
- CEMental Health Provider - Inpatient
- CFMental Health Provider - Outpatient
- CGMental Health Facility - Inpatient
- CHMental Health Facility - Outpatient
- CISubstance Abuse Facility - Inpatient
- CJSubstance Abuse Facility - Outpatient
- CKScreening X-ray
- CLScreening laboratory
- CMMammogram, High Risk Patient
- CNMammogram, Low Risk Patient
- COFlu Vaccination
- CPEyewear and Eyewear Accessories
- CQCase Management
- DGDermatology
- DMDurable Medical Equipment
- DSDiabetic Supplies
- GFGeneric Prescription Drug - Formulary
- GNGeneric Prescription Drug - Non-Formulary
- GYAllergy
- ICIntensive Care
- MHMental Health
- NINeonatal Intensive Care
- ONOncology
- PTPhysical Therapy
- PUPulmonary
- RNRenal
- RTResidential Psychiatric Treatment
- TCTransitional Care
- TNTransitional Nursery Care
- UCUrgent Care
Code indicating the level of coverage being provided for this insured
Codes (25)- CHDChildren Only
- DEPDependents Only
- E1DEmployee and One Dependent
- E2DEmployee and Two Dependents
- E3DEmployee and Three Dependents
- E5DEmployee and One or More Dependents
- E6DEmployee and Two or More Dependents
- E7DEmployee and Three or More Dependents
- E8DEmployee and Four or More Dependents
- E9DEmployee and Five or More Dependents
- ECHEmployee and Children
- EMPEmployee Only
- ESPEmployee and Spouse
- FAMFamily
- INDIndividual
- S1CSubscriber and 1 child
- S5CSubscriber and 1 or more children
- S6CSubscriber and 2 or more children
- SPCSpouse and Children
- SPOSpouse Only
- SS1Subscriber, spouse, and 1 child
- SS5Subscriber, spouse, and 1 or more children
- SS6Subscriber, spouse, and 2 or more children
- SSPSubscriber and spouse
- TWOTwo Party
Code identifying the type of insurance policy within a specific insurance program
Codes (51)- 12Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14Medicare Secondary, No-fault Insurance including Auto is Primary
- 15Medicare Secondary Worker's Compensation
- 16Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 17Dental
- 18Vision
- 19Prescription Drugs
- 41Medicare Secondary Black Lung
- 42Medicare Secondary Veteran's Administration
- 43Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- 47Medicare Secondary, Other Liability Insurance is Primary
- DDisability
- EMedicare - Point of Service (POS)
- UMultiple Options Health Plan
- APAuto Insurance Policy
- C1Commercial
- COConsolidated Omnibus Budget Reconciliation Act (COBRA)
- CPMedicare Conditionally Primary
- DBDisability Benefits
- EPExclusive Provider Organization
- FFFamily or Friends
- GPGroup Policy
- HMHealth Maintenance Organization (HMO)
- HNHealth Maintenance Organization (HMO) - Medicare Risk
- HSSpecial Low Income Medicare Beneficiary
- INIndemnity
- IPIndividual Policy
- LCLong Term Care
- LDLong Term Policy
- LILife Insurance
- LTLitigation
- MAMedicare Part A
- MBMedicare Part B
- MCMedicaid
- MDMedicare Part D
- MHMedigap Part A
- MIMedigap Part B
- MPMedicare Primary
- OTOther
- PEProperty Insurance - Personal
- PLPersonal
- PPPersonal Payment (Cash - No Insurance)
- PRPreferred Provider Organization (PPO)
- PSPoint of Service (POS)
- QMQualified Medicare Beneficiary
- RPProperty Insurance - Real
- SPSupplemental Policy
- TFTax Equity Fiscal Responsibility Act (TEFRA)
- WCWorkers Compensation
- WUWrap Up Policy