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Segment
in
X12 Release 003040

EB Eligibility or Benefit Information

To supply eligibility or benefit information
Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
1390
Eligibility or Benefit Information
Identifier (ID)
Mandatory
1
2
-
Code identifying eligibility or benefit information
EB01 qualifies EB06 thru EB10.
Codes (30)
02
Coverage Level Code
Identifier (ID)
Optional
3
3
-
Code indicating the level of coverage being provided for this insured
Codes (18)
03
Service Type Code
Identifier (ID)
Optional
1
2
-
Code identifying the classification of service
Codes (117)
04
Insurance Type Code
Identifier (ID)
Optional
1
3
-
Code identifying the type of insurance policy within a specific insurance program
Codes (30)
05
Plan Coverage Description
String (AN)
Optional
1
50
-
A description or number that identifies the plan or coverage.
06
Time Period Qualifier
Identifier (ID)
Optional
1
2
-
Code defining periods.
Codes (34)
07
Monetary Amount
Decimal number (R)
Optional
1
15
-
Monetary amount.
08
Percent
Decimal number (R)
Optional
1
10
-
Percentage expressed as a decimal
09
Quantity Qualifier
Identifier (ID)
Conditional
2
2
-
Code specifying the type of quantity.
P0910
Codes (326)
10
Quantity
Decimal number (R)
Conditional
1
15
-
Numeric value of quantity.
11
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response.
EB11 is the Authorization or Certification Indicator. A ``Y'' value indicates that an authorization or certification is required per plan provisions. A ``N'' value indicates that an authorization or certification is not required per plan provisions. A ``U'' value indicates it is unknown whether the plan provisions require an authorization or certification.
Codes (3)
12
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response.
EB12 is the Plan Network Indicator. A ``Y'' value indicates the benefits identified are considered In-Plan-Network. A ``N'' value indicates that the benefits identified are considered Out-Of-Plan-Network. A ``U'' value indicates it is unknown whether the benefits identified are part of the Plan Network.
Codes (3)
13
Composite Medical Procedure Identifier
Composite (composite)
Optional
01
Product/Service ID Qualifier
Identifier (ID)
Mandatory
2
2
-
Code identifying the type/source of the descriptive number used in Product/Service ID (234).
Codes (307)
02
Product/Service ID
String (AN)
Mandatory
1
30
-
Identifying number for a product or service.
03
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-03 modifies the value in C003-02.
04
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-04 modifies the value in C003-02.
05
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-05 modifies the value in C003-02.
06
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-06 modifies the value in C003-02.
07
Description
String (AN)
Optional
1
80
-
A free-form description to clarify the related data elements and their content.
C003-07 is the description of the procedure identified in C003-02.
Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.
Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.