Schema name: X12_00501_270
Eligibility, Coverage or Benefit Inquiry
Transaction Set Header
Transaction Set Identifier Code_143
Transaction Set Control Number_329
Implementation Convention Reference_1705
Transaction Set Trailer
Number of Included Segments_96
Transaction Set Control Number_329
Loop for Information Source Name
Loop for Information Receiver Name
Loop for Subscriber Eligibility or Benefit Inquiry
Loop for Subscriber Name
Loop for Dependent Eligibility or Benefit Inquiry
Loop for Dependent Name
Loop for Dependent Level
Loop for Subscriber Level
Loop for Information Receiver Level
Loop for Information Source Level
Beginning of Hierarchical Transaction
Hierarchical Structure Code_1005
Transaction Set Purpose Code_353
Reference Identification_127
Date_373
Time_337
Transaction Type Code_640
Information Source Level
Hierarchical ID Number_628
Hierarchical Parent ID Number_734
Hierarchical Level Code_735
Hierarchical Child Code_736
Information Source Name
Entity Identifier Code_98
Entity Type Qualifier_1065
Name Last or Organization Name_1035
Name First_1036
Name Middle_1037
Name Prefix_1038
Name Suffix_1039
Identification Code Qualifier_66
Identification Code_67
Entity Relationship Code_706
Entity Identifier Code_98
Name Last or Organization Name_1035
Information Receiver Level
Hierarchical ID Number_628
Hierarchical Parent ID Number_734
Hierarchical Level Code_735
Hierarchical Child Code_736
Information Receiver Name
Entity Identifier Code_98
Entity Type Qualifier_1065
Name Last or Organization Name_1035
Name First_1036
Name Middle_1037
Name Prefix_1038
Name Suffix_1039
Identification Code Qualifier_66
Identification Code_67
Entity Relationship Code_706
Entity Identifier Code_98
Name Last or Organization Name_1035
Information Receiver Additional Identification
Reference Identification Qualifier_128
Reference Identification_127
Description_352
Information Receiver Address
Address Information_166
Address Information_166
Information Receiver City, State, ZIP Code
City Name_19
State or Province Code_156
Postal Code_116
Country Code_26
Location Qualifier_309
Location Identifier_310
Country Subdivision Code_1715
Information Receiver Provider Information
Provider Code_1221
Reference Identification Qualifier_128
Reference Identification_127
State or Province Code_156
Provider Organization Code_1223
Subscriber Level
Hierarchical ID Number_628
Hierarchical Parent ID Number_734
Hierarchical Level Code_735
Hierarchical Child Code_736
Subscriber Trace Number
Trace Type Code_481
Reference Identification_127
Originating Company Identifier_509
Reference Identification_127
Subscriber Name
Entity Identifier Code_98
Entity Type Qualifier_1065
Name Last or Organization Name_1035
Name First_1036
Name Middle_1037
Name Prefix_1038
Name Suffix_1039
Identification Code Qualifier_66
Identification Code_67
Entity Relationship Code_706
Entity Identifier Code_98
Name Last or Organization Name_1035
Subscriber Additional Identification
Reference Identification Qualifier_128
Reference Identification_127
Description_352
Subscriber Address
Address Information_166
Address Information_166
Subscriber City, State, ZIP Code
City Name_19
State or Province Code_156
Postal Code_116
Country Code_26
Location Qualifier_309
Location Identifier_310
Country Subdivision Code_1715
Provider Information
Provider Code_1221
Reference Identification Qualifier_128
Reference Identification_127
State or Province Code_156
Provider Organization Code_1223
Subscriber Demographic Information
Date Time Period Format Qualifier_1250
Date Time Period_1251
Gender Code_1068
Marital Status Code_1067
Citizenship Status Code_1066
Country Code_26
Basis of Verification Code_659
Quantity_380
Code List Qualifier Code_1270
Industry Code_1271
Multiple Birth Sequence Number
Yes/No Condition or Response Code_1073
Individual Relationship Code_1069
Maintenance Type Code_875
Maintenance Reason Code_1203
Benefit Status Code_1216
Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code_1219
Employment Status Code_584
Student Status Code_1220
Yes/No Condition or Response Code_1073
Date Time Period Format Qualifier_1250
Date Time Period_1251
Confidentiality Code_1165
City Name_19
State or Province Code_156
Country Code_26
Number_1470
Subscriber Health Care Diagnosis Code
Subscriber Date
Date/Time Qualifier_374
Date Time Period Format Qualifier_1250
Date Time Period_1251
Subscriber Eligibility or Benefit Inquiry
Service Type Code_1365
Coverage Level Code_1207
Insurance Type Code_1336
Subscriber Spend Down Amount
Amount Qualifier Code_522
Monetary Amount_782
Credit/Debit Flag Code_478
Subscriber Spend Down Total Billed Amount
Amount Qualifier Code_522
Monetary Amount_782
Credit/Debit Flag Code_478
Subscriber Eligibility or Benefit Additional Inquiry Information
Code List Qualifier Code_1270
Industry Code_1271
Code Category_1136
Free-form Message Text_933
Quantity_380
Surface/Layer/Position Code_752
Surface/Layer/Position Code_752
Surface/Layer/Position Code_752
Subscriber Additional Information
Reference Identification Qualifier_128
Reference Identification_127
Description_352
Subscriber Eligibility/Benefit Date
Date/Time Qualifier_374
Date Time Period Format Qualifier_1250
Date Time Period_1251
Dependent Level
Hierarchical ID Number_628
Hierarchical Parent ID Number_734
Hierarchical Level Code_735
Hierarchical Child Code_736
Dependent Trace Number
Trace Type Code_481
Reference Identification_127
Originating Company Identifier_509
Reference Identification_127
Dependent Name
Entity Identifier Code_98
Entity Type Qualifier_1065
Name Last or Organization Name_1035
Name First_1036
Name Middle_1037
Name Prefix_1038
Name Suffix_1039
Identification Code Qualifier_66
Identification Code_67
Entity Relationship Code_706
Entity Identifier Code_98
Name Last or Organization Name_1035
Dependent Additional Identification
Reference Identification Qualifier_128
Reference Identification_127
Description_352
Dependent Address
Address Information_166
Address Information_166
Dependent City, State, ZIP Code
City Name_19
State or Province Code_156
Postal Code_116
Country Code_26
Location Qualifier_309
Location Identifier_310
Country Subdivision Code_1715
Provider Information
Provider Code_1221
Reference Identification Qualifier_128
Reference Identification_127
State or Province Code_156
Provider Organization Code_1223
Dependent Demographic Information
Date Time Period Format Qualifier_1250
Date Time Period_1251
Gender Code_1068
Marital Status Code_1067
Citizenship Status Code_1066
Country Code_26
Basis of Verification Code_659
Quantity_380
Code List Qualifier Code_1270
Industry Code_1271
Dependent Relationship
Yes/No Condition or Response Code_1073
Individual Relationship Code_1069
Maintenance Type Code_875
Maintenance Reason Code_1203
Benefit Status Code_1216
Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code_1219
Employment Status Code_584
Student Status Code_1220
Yes/No Condition or Response Code_1073
Date Time Period Format Qualifier_1250
Date Time Period_1251
Confidentiality Code_1165
City Name_19
State or Province Code_156
Country Code_26
Number_1470
Dependent Health Care Diagnosis Code
Dependent Date
Date/Time Qualifier_374
Date Time Period Format Qualifier_1250
Date Time Period_1251
Dependent Eligibility or Benefit Inquiry
Service Type Code_1365
Coverage Level Code_1207
Insurance Type Code_1336
Dependent Eligibility or Benefit Additional Inquiry Information
Code List Qualifier Code_1270
Industry Code_1271
Code Category_1136
Free-form Message Text_933
Quantity_380
Surface/Layer/Position Code_752
Surface/Layer/Position Code_752
Surface/Layer/Position Code_752
Dependent Additional Information
Reference Identification Qualifier_128
Reference Identification_127
Description_352
Dependent Eligibility/Benefit Date
Date/Time Qualifier_374
Date Time Period Format Qualifier_1250
Date Time Period_1251
Reference Identifier
Reference Identification Qualifier_128
Reference Identification_127
Reference Identification Qualifier_128
Reference Identification_127
Reference Identification Qualifier_128
Reference Identification_127
Provider Specialty Information
Provider Specialty Code_1222
Agency Qualifier Code_559
Yes/No Condition or Response Code_1073
Reference Identifier
Reference Identification Qualifier_128
Reference Identification_127
Reference Identification Qualifier_128
Reference Identification_127
Reference Identification Qualifier_128
Reference Identification_127
Provider Specialty Information
Provider Specialty Code_1222
Agency Qualifier Code_559
Yes/No Condition or Response Code_1073
Composite Race or Ethnicity Information
Race or Ethnicity Code_1109
Code List Qualifier Code_1270
Industry Code_1271
Medicare Status Code
Medicare Plan Code_1218
Eligibility Reason Code_1701
Eligibility Reason Code_1701
Eligibility Reason Code_1701
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Composite Medical Procedure Identifier
Product/Service ID Qualifier_235
Product/Service ID_234
Procedure Modifier_1339
Procedure Modifier_1339
Procedure Modifier_1339
Procedure Modifier_1339
Description_352
Product/Service ID_234
Composite Diagnosis Code Pointer
Diagnosis Code Pointer_1328
Diagnosis Code Pointer_1328
Diagnosis Code Pointer_1328
Diagnosis Code Pointer_1328
Composite Unit of Measure
Unit or Basis for Measurement Code_355
Exponent_1018
Multiplier_649
Unit or Basis for Measurement Code_355
Exponent_1018
Multiplier_649
Unit or Basis for Measurement Code_355
Exponent_1018
Multiplier_649
Unit or Basis for Measurement Code_355
Exponent_1018
Multiplier_649
Unit or Basis for Measurement Code_355
Exponent_1018
Multiplier_649
Reference Identifier
Reference Identification Qualifier_128
Reference Identification_127
Reference Identification Qualifier_128
Reference Identification_127
Reference Identification Qualifier_128
Reference Identification_127
Reference Identifier
Reference Identification Qualifier_128
Reference Identification_127
Reference Identification Qualifier_128
Reference Identification_127
Reference Identification Qualifier_128
Reference Identification_127
Provider Specialty Information
Provider Specialty Code_1222
Agency Qualifier Code_559
Yes/No Condition or Response Code_1073
Composite Race or Ethnicity Information
Race or Ethnicity Code_1109
Code List Qualifier Code_1270
Industry Code_1271
Medicare Status Code
Medicare Plan Code_1218
Eligibility Reason Code_1701
Eligibility Reason Code_1701
Eligibility Reason Code_1701
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Health Care Code Information
Code List Qualifier Code_1270
Industry Code_1271
Date Time Period Format Qualifier_1250
Date Time Period_1251
Monetary Amount_782
Quantity_380
Version Identifier_799
Industry Code_1271
Yes/No Condition or Response Code_1073
Composite Medical Procedure Identifier
Product/Service ID Qualifier_235
Product/Service ID_234
Procedure Modifier_1339
Procedure Modifier_1339
Procedure Modifier_1339
Procedure Modifier_1339
Description_352
Product/Service ID_234
Composite Diagnosis Code Pointer
Diagnosis Code Pointer_1328
Diagnosis Code Pointer_1328
Diagnosis Code Pointer_1328
Diagnosis Code Pointer_1328
Composite Unit of Measure
Unit or Basis for Measurement Code_355
Exponent_1018
Multiplier_649
Unit or Basis for Measurement Code_355
Exponent_1018
Multiplier_649
Unit or Basis for Measurement Code_355
Exponent_1018
Multiplier_649
Unit or Basis for Measurement Code_355
Exponent_1018
Multiplier_649
Unit or Basis for Measurement Code_355
Exponent_1018
Multiplier_649
Reference Identifier
Reference Identification Qualifier_128
Reference Identification_127
Reference Identification Qualifier_128
Reference Identification_127
Reference Identification Qualifier_128
Reference Identification_127