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Segment
in
X12 Release 008010

EQ Eligibility or Benefit Inquiry

To specify inquired eligibility or benefit information
Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
C064
Service Type
Composite (composite)
Conditional
99
01
Industry Code
String (AN)
Mandatory
1
30
-
Code indicating a code from a specific industry code list
C064-01 is the Service Type (Code Source 958).
02
Industry Code
String (AN)
Optional
1
30
-
Code indicating a code from a specific industry code list
C064-02 is the Service Type Descriptor (Code Source 981).
02
Composite Medical Procedure Identifier
Composite (composite)
Conditional
99
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)
C003-01 qualifies C003-02 and C003-08.
Codes (544)
02
Product/Service ID
String (AN)
Mandatory
1
80
-
Identifying number for a product or service
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
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 and C003-08.
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 and C003-08.
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 and C003-08.
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 and C003-08.
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.
08
Product/Service ID
String (AN)
Optional
1
80
-
Identifying number for a product or service
C003-08 represents the ending value in the range in which the code occurs.
09
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-09 modifies the value in C003-02 and C003-08.
10
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-10 modifies the value in C003-02 and C003-08.
11
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-11 modifies the value in C003-02 and C003-08.
12
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-12 modifies the value in C003-02 and C003-08.
03
Coverage Level Code
Identifier (ID)
Optional
3
3
1
Code indicating the level of coverage being provided for this insured
Codes (25)
04
Insurance Product Code
Identifier (ID)
Optional
1
3
1
Code identifying the type of insurance policy within a specific insurance program for eligibility purposes.
05
Diagnosis Code Pointer
Numeric (N0)
Optional
1
2
12
A pointer to the diagnosis code in the order of importance to this service
The first pointer designates the primary diagnosis and remaining diagnosis pointers indicate declining level of importance.
06
Network Indicator Code
Identifier (ID)
Optional
1
2
1
Code identifying a health plan network status.
Codes (4)
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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.