Eligibility Messaging

29 min

This section provides guidelines for the data messaging interfaces between the provider vendor or pharmacy and PBM/payers. Standard segments will be required for commonly transmitted data such as basic patient demographics and eligibility information.

The Patient and Eligibility Data will be transmitted between the provider vendor or pharmacy system, Surescripts, and PBM/payer using the currently accepted X12 envelope segments. Message formats used include the X12 Eligibility Request (Health Care Eligibility Benefit Inquiry) and the X12 Eligibility Response (Health Care Eligibility Benefit Response).

The requester is a provider vendor or pharmacy system, and the eligibility responder is a PBM/payer.

See Eligibility Premium FeaturesEligibility Premium Features for more information.

Relationship to the X12 Eligibility Request and Eligibility Response Standard

All eligibility requests and responses sent to Surescripts by customers must comply with the X12 standard for eligibility for a health plan mandated under HIPAA by the Department of Health and Human Services (the "270/271 Implementation Guide"). The descriptions in this section of Eligibility Request transactions and the Eligibility Response transactions clarify the information that Surescripts expects to be included in Eligibility Request and Eligibility Response messages exchanged with Surescripts. Nothing in these Specifications are intended or shall be deemed to: (a) change the definition, data condition, or use of a data element or segment in a HIPAA-mandated standard; (b) add any data elements or segments to the maximum defined data set of a HIPAA-mandated standard; (c) use any code or data elements that are either marked "not used" in the 270/271 Implementation Guide; or (d) change the meaning or intent of the 270/271 Implementation Guide.

The guidelines for data messaging interfaces provided in this document are tailored to the needs of provider vendor system and PBM/payer customers related to prescription drug benefits and are a subset of the X12 standard. The X12 standard covers a great number of other business scenarios that are not described in this section; however, Surescripts will support the minimum requirements of the X12 Eligibility Request/Eligibility Response transaction. See Section 1.4.7 of the 270/271 Implementation Guide (“Implementation Compliant Use of the 270/271 Transaction Set”).

Note: Even though Surescripts has implemented a subset of the X12N 270/271 standard, customers should be able to handle receiving all the segments, elements and related codes contained in the HIPAA X12N 270/271 standard. Refer to the Document ReferencesDocument References for the exact reference guides needed.

If a provider vendor submits an Eligibility Request that does not comply with the X12 standard, Surescripts will return a 999 response. If a provider vendor system customer submits an Eligibility Request that complies with the X12 Eligibility Request/Eligibility Response transaction but contains information that is unexpected by Surescripts, Surescripts will return an Eligibility Response based on the information received by Surescripts that was expected, but the response may include AAA segments if insufficient information expected by Surescripts is submitted to generate a meaningful response.

If a PBM/payer customer submits an Eligibility Response that does not comply with the X12 standard, Surescripts will return a 999 response to the PBM/payer. The response to the PBM/payer should be responded to with an ACK. If a PBM/payer customer submits an Eligibility Response that complies with the X12 Eligibility Request/Eligibility Response transaction but contains information that is unexpected by Surescripts, Surescripts will pass the response to the requesting provider vendor system. However, PBM/payer customers should be aware that such responses may not be understood or usable by the recipient provider vendor system.

Patient Match Verification

The specific fields that are used to match the patient are listed below. Only valid patient data should be entered. Invalid data or filler data may result in “patient not found” or an incorrect match.

Last Name NM103

First Name NM104 – Use formal name. Do not use preferred name or nickname.

Middle Name NM105

Suffix NM107 – If relevant, the name suffix should be included in this field.

Street Address (line 1) N301

Street Address (line 2) N302

City N401

State N402

Zip N403

DOB DMG02

Gender DMG03

Insufficient Information

In the event that insufficient identifying elements are sent to Surescripts to uniquely identify a patient, Surescripts returns an Eligibility Response with an AAA segment identifying “Subscriber/Insured Not Found” or “Patient Not Found” and sends recommendations for future searches, if appropriate.

Patient Not Found with Hint Errors

When ”Patient Not Found with Hint” error message is received in an AAA response, the provider vendor system should work to correct and resubmit, including those fields that would assist in identifying the patient. The error is sent if patient is not found and one or more of the following fields are missing:

Patient First Name

Patient Last Name

Patient Zip Code

Patient Date-of-Birth

Sending all fields will aid in locating more patients, enabling more informed decision making during the prescribing process.

Non-Unique Match

In the event that multiple patients are found for the submitted data elements and a unique match cannot be determined, Surescripts returns an Eligibility Response with an AAA segment identifying “Subscriber/Insured Not Found or Patient Not Found” and, if possible, lists the missing data elements needed to help identify an exact patient match.

PBM/payers assign a unique ID to each covered member. For this reason, customers should use the subscriber loop since each member is being treated as a subscriber according to the standard.

Note: PBM/payers should always return the data they had in their system in the Eligibility Response and not echo back what was sent in the Eligibility Request.

If any of the demographic fields listed above are different from what the provider vendor sent, a change flag is returned from the PBM/payer. If a field comes in blank and the PBM/payer sends back a value, this is considered a change. However, if the provider vendor sends a value in a field and the PBM/payer is unable to compare this field because they do not store this field in their patient data, the change flag must not be set and the data from the request must not be returned.

The change flag is in the INS segment. INS03 = 001, INS04 = 25.

In the case of error conditions including patient not found - AAA error 75, contract /authorization error - AAA error 41, and general system errors – AAA error 42, do not send back patient information from the Eligibility Request. Therefore, in these error conditions, no patient data should be sent back. The provider vendor should disregard any patient information under these error scenarios.

Examples:

This is an example where the PBM/payer should indicate that a change has been made and set the change flag in the INS segment.

Provider vendor sends: Joe M Doe, DOB 19550412, Gender Male, and Address 55 HIGH STREET, SEATTLE, WA 55111 PBM/payer returns: Joseph M Doe, DOB 19550412, Gender Male, and Address 55 HIGH STREET, St. Paul, MN 55111 In this example, the PBM/payer does not need to set the change flag because they have not changed any of the information returned, but the middle initial is blank due to the field not being supported in the PBM/payer’s system:

Provider vendor sends: Joe M Doe, DOB 19550412, Gender Male, and Address 55 HIGH STREET, St. Paul MN, 55111 PBM/payer returns: Joe Doe, DOB 19550412, Gender Male, and Address 55 HIGH STREET, St. Paul MN, 55111 In this example, the PBM/payer looks up the information and finds a blank for the middle name (which is a supported field in the PBM/payer’s system). This is considered a change so the change flag needs to be set:

Provider vendor sends: Joe M Doe, DOB 19550412, Gender Male, PBM/payer returns: Joe Doe, DOB 19550412, Gender Male, This is an example where the patient is not found, so none of the patient information is returned. Provider vendor sends: Joe M Doe, DOB 19550412, Gender Male, and Address 55 HIGH STREET, St. Paul MN 55111 PBM/payer returns: No Patient Data and an AAA segment with error 75 – Subscriber/Insured Not Found.

270 Eligibility, Coverage, or Benefit Inquiry

This section contains a subset of information on the Eligibility, Coverage, or Benefit Inquiry Transaction Set (270) for use within the context of an E-Prescribing environment.

Since PBM/payers uniquely identify each member, the subscriber level should be used instead of the dependent level. However, receivers of the Eligibility Request are required to be able to handle patients at the dependent level since the standard allows it.

Reference: ASC X12N/005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) Sec. 1.4.2: Page 5.

Notes:

This guide only includes data elements where Surescripts has specific requirements or further explains the field usage. Refer to X12N/005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) for a complete list of segments and elements. In addition, comments below where codes are specified are either to call out Surescripts notes and/or to show the code recommended by Surescripts. For a full list of codes, please refer to X12N/005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271).

Unless specified otherwise, the information in the tables below apply to both Eligibility and Eligibility for Pharmacy.

Elements that are grouped together may be marked as mandatory; however, if the group itself is marked as conditional or recommended, then these are only required if you use the group.

Requirement Designation

Code	Description
mandatory	The element must be used per the specification (e.g., XML schema validation). Note: The term mandatory applies to mandatory and required fields in the different standards.
business rule	If sent, the element must be used per the Surescripts business rule. Note: Not all business rules reside in this table.
conditional	The element is to be used per the conditions specified. Note: The term conditional applies to conditional and situational fields in the different standards. For example, X12 uses the term situational.
recommended	Surescripts recommends sending the element as a best practice.
optional	Some fields do not have specific conditions. Data should be sent if available.
not used	Not used by Surescripts.

Header

Segment ID (Eligibility Request)	Segment Name (Eligibility Request)	Code	Comments
ISA	Interchange Control Header	mandatory
ISA01	Authorization Information Qualifier	mandatory	Value: 00 - No Authorization Information Present (No Meaningful Information in Data Element I02)
ISA02	Authorization Information	mandatory	Not used. Fill with blanks.
ISA03	Security Information Qualifier	mandatory	Code to identify the type of information in the Security Information. Value: 01 - Password
ISA04	Security Information	mandatory	From the provider vendor, this is the Password assigned by Surescripts for the provider vendor. From Surescripts, this is the password Surescripts uses when sending to the PBM/Payer.
ISA05	Interchange ID Qualifier	mandatory	Qualifier: ZZ - Mutually Defined
ISA06	Interchange Sender ID	mandatory	From the provider vendor system, this is the Participant ID as assigned by Surescripts. From Surescripts to the PBM/payer, this is Surescripts’ ID.
ISA07	Interchange ID Qualifier	mandatory	Qualifier ZZ - Mutually Defined
ISA08	Interchange Receiver ID	mandatory	From the provider vendor system to Surescripts, the provider vendor system must use the Surescripts ID designated by Surescripts Integration for the customer’s specific use case. From the pharmacy to Surescripts, the pharmacy system must use the Surescripts ID S00000000000010. From Surescripts to the PBM/payer, this is PBM/payer's Participant ID. For a full list of possible Surescripts IDs that relate to Eligibility, see Appendix C: Surescripts Eligibility IdentifiersAppendix C: Surescripts Eligibility Identifiers.
ISA09	Interchange Date	mandatory	Date format YYMMDD required
ISA10	Interchange Time	mandatory	Time format HHMM required.
ISA11	Repetition Separator	mandatory	Surescripts recommends using Hex 1F.
ISA12	Interchange Control Version Number	mandatory	This version number covers the interchange control segments. 00501 – Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA13	Interchange Control Number	mandatory	From the provider vendor system, this is a unique ID assigned by the provider vendor system for transaction tracking. From Surescripts, this is a unique ID assigned by Surescripts for transaction tracking. This ID will be returned on a TA1 if an error occurs. Providing a unique number will assist in resolving errors and tracking messages.
ISA14	Acknowledgement Requested	mandatory	Since these transactions are real time only, Surescripts does not use this field to determine whether to create a TA1 acknowledgment. Value: 0 - No Acknowledgment Requested (Recommended by Surescripts)
ISA15	Interchange Usage Indicator	mandatory	Values: P - Production Data T - Test Data
ISA16	Component Element Separator	mandatory	Surescripts recommends using Hex 1C.
GS	Functional Group Header	mandatory
GS01	Functional Identifier Code	mandatory	Value: HS
GS02	Application Sender’s Code	mandatory	From the provider vendor system, this is the Participant ID as assigned by Surescripts. From Surescripts to PBM/payer, this is Surescripts’ ID.
GS03	Application Receiver’s Code	mandatory	From the provider vendor system to Surescripts, the provider vendor system must use the Surescripts ID designated by Surescripts Integration for the customer’s specific use case. From the pharmacy to Surescripts, the pharmacy system must use the Surescripts ID S00000000000010. From Surescripts to PBM/payer, this is PBM/payer's Participant ID. For a full list of possible Surescripts IDs that relate to Eligibility, see Appendix C: Surescripts Eligibility IdentifiersAppendix C: Surescripts Eligibility Identifiers.
GS06	Group Control Number	mandatory	The control number should be unique across all groups within this transaction set. This ID will be returned on an AK102 of the 999 acknowledgment if an error occurs. Providing unique numbers will assist in resolving errors and tracking messages. Avoid using leading zeros in this field.
ST	Transaction Set Header	mandatory
ST02	Transaction Set Control Number	mandatory	Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set. The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with the number, for example "0001", and increment from there. This number must be unique within a specific group and interchange, but can repeat in other groups and interchanges. Note: This ID will be returned on an AK202 of the 999 acknowledgment if an error occurs. Providing a unique number will assist in resolving errors and tracking messages.
BHT	Beginning of Hierarchical Transaction	mandatory
BHT02	Transaction Set Purpose Code	mandatory	Value: 13 - Request (Surescripts customers utilize this option only.)
BHT03	Reference Identification	mandatory	Because Surescripts only supports Real Time, this element is required.

Detail

Segment ID (Eligibility Request)	Segment Name (Eligibility Request)	Code	Comments
Loop ID – 2000A Information Source Level
HL	Information Source Level (PBM/payer)	mandatory
Loop ID – 2100A Information Source Name
NM1	Information Source Name	mandatory
NM101	Entity Identifier Code	mandatory	Value: 2B - Third-Party Administrator (Recommended by Surescripts)
NM102	Entity Type Qualifier	mandatory	Value: 2 - Non-Person Entity (Recommended by Surescripts)
NM103	Name Last	mandatory	From the provider vendor system, the source is unknown so this would be Surescripts. From Surescripts, Surescripts will place the source name here.
NM108	Identification Code Qualifier	mandatory	Value: PI - Payer Identification (Recommended by Surescripts)
NM109	Identification Code	mandatory	From the provider vendor system to Surescripts, the provider vendor system must use the Surescripts ID designated by Surescripts Integration for the customer’s specific use case. From the pharmacy to Surescripts, the pharmacy system must use the Surescripts ID S00000000000010. From Surescripts to PBM/payer, Surescripts will place the Participant ID of the PBM/payer's here. For a full list of possible Surescripts IDs that relate to Eligibility, see Appendix C: Surescripts Eligibility IdentifiersAppendix C: Surescripts Eligibility Identifiers.
Loop ID – 2000B Information Receiver Level
HL	Information Receiver Level (Physician)	mandatory
Loop ID – 2100B Information Receiver Name
NM1	Information Receiver Name	mandatory
NM101	Entity Identifier Code	mandatory	Value: 1P - Provider (Recommended by Surescripts)
NM102	Entity Type Qualifier	mandatory	Indicates if the entity is an individual person or an organization. Value: 1 - Person (Recommended by Surescripts for Eligibility) 2 - Non-Person Entity (Recommended by Surescripts for Eligibility for Pharmacy)
NM103	Name Last or Organization Name	mandatory	If value "1" was sent in NM102, the individual’s last name (physician’s last name) is sent in this field. If value "2" was sent in NM102, the organization name is sent in this field.
NM108	Identification Code Qualifier	mandatory	Qualifier: XX - Centers for Medicare and Medicaid Services National Provider Identifier.
NM109	Identification Code	mandatory	The NPI is mandated. Surescripts will reject if the NM108 and the NM109 are not populated. The NPI will follow a two-step validation process: The NPI check digit will be validated using the LUHN formula. For specific information see: https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/NPIcheckdigit.pdf Notes: It may take up to one week for an NPI to become active in the Surescripts directory. The NPPES validation process is only applicable in the production environment.
REF	Information Receiver Additional Identification (Provider Vendor System Identification)	conditional
REF01	Reference Identification Qualifier	mandatory	Value: EO – Submitter Identification Number (A unique number identifying the submitter of the transaction set.)
REF02	Reference Identification	mandatory	Surescripts defined Participant ID for the provider vendor system. business rule REF*EO must match the ISA-06 on the incoming Eligibility Request.
REF03	Description	conditional	Must not be used for the EO qualifier.
N3	Information Receiver Address	conditional	Required when the information receiver is a provider who has multiple locations and it is needed to identify the location relative to the request.
N4	Information Receiver City/State/ZIP Code	conditional	Required when the information receiver is a provider who has multiple locations and it is needed to identify the location relative to the request.
N401	City Name	mandatory
N402	State or Province Code	conditional	This field is required if City Name (N401) is in the U.S. or Canada.
N403	Postal Code	conditional	This field is required if City Name (N401) is in the U.S. or Canada.
N404	Country Code	conditional	Do not send the US Country Code.
Loop ID – 2000C Subscriber Level
HL	Subscriber Level	mandatory
TRN	Subscriber Trace Number	conditional
Loop ID – 2100C Subscriber Name
NM1	Subscriber Name	mandatory
NM103	Name Last or Organization Name	recommended	Individual’s last name or organization name.
NM104	Name First	recommended	Individual’s first name. Use formal name. Do not use preferred name or nickname.
NM105	Name Middle	recommended	Middle name or initial.
NM107	Name Suffix	recommended	Suffix to individual’s name. If applicable, the name suffix should be included in this field.
NM108	Identification Code Qualifier	conditional	From the provider vendor system this is blank. Surescripts will put the Qualifier "MI" into this field. Value: MI - Member Identification Number
NM109	Identification Code	conditional	From the provider vendor system this is blank. Surescripts will put the PBM Unique Member ID into this field.
REF	Subscriber Additional Identification (SSN#, Person Code)	conditional
N3	Subscriber Address	conditional
N301	Address Information	mandatory	Address information.
N4	Subscriber City/State/ZIP Code	recommended	Surescripts strongly recommends sending this segment to aid in patient matching. If this field is not sent, the patient may not be found.
N401	City Name	mandatory
N402	State or Province Code	recommended	This field is required if City Name (N401) is in the U.S. or Canada.
N403	Postal Code	recommended	This field is required if City Name (N401) is in the U.S. or Canada.
N404	Country Code	conditional	Do not send US Country Code.
DMG	Subscriber Demographic Information	conditional
DMG02	Date Time Period	recommended	Use this date for the date of birth of the individual.
DMG03	Gender Code	recommended	Code indicating the sex of the individual. Values: F – Female M – Male If the sex of the individual is unknown or other, do not send this field in the Eligibility Request.
DTP	Subscriber Date	conditional	Absence of a Plan date indicates the request is for the date the transaction is processed and the information source is to process the transaction in the same manner as if the processing date was sent. The Eligibility Date of Service and the Eligibility Transmission Date must be within three (3) days of the patient interaction (Past and Future).
Loop ID - 2110C Subscriber Eligibility or Benefit Inquiry
EQ	Subscriber Eligibility or Benefit Inquiry Information (Health Benefit Plan Coverage)	conditional
EQ01	Service Type Code	conditional	Value: 30 - Health Benefit Plan Coverage (Recommended by Surescripts) Instead of specifying a specific service type code, this code allows the information source to respond with all the relevant service types. If other service types are sent, the responder will only respond to pharmacy-related coverages. An information source may support the use of Service Type Codes other than “30" (Health Benefit Plan Coverage) in EQ01 at their discretion.

Trailer

Segment ID (Eligibility Request)	Segment Name (Eligibility Request)	Code
SE	Transaction Set Trailer	mandatory
GE	Functional Group Trailer	mandatory
IEA	Interchange Control Trailer	mandatory

271 Eligibility, Coverage, or Benefit Information

This section contains a subset of information on the Eligibility, Coverage, or Benefit Information Transaction Set (271) for use within the context of E-Prescribing.

PBM/payer's uniquely identify each patient, thus the subscriber level should be used instead of the dependent level. However, receivers of the Eligibility Request are required to be able to handle patients at the dependent level since the standard allows it. Also, when the patient is submitted in the dependent loop (in Eligibility Request) they must be returned in the subscriber loop (in Eligibility Response). This is due to the fact that PBM/payer's assign unique identifiers to all members thus they are deemed to be subscribers according to the standard.

Notes:

This guide only includes data elements where Surescripts has specific requirements or further explains the field usage. Refer to X12N/005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) for a complete list of segments and elements. In addition, comments below where codes are specified are either to call out Surescripts notes and/or to show the code recommended by Surescripts. For a full list of codes, please refer to X12N/005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271).

Unless specified otherwise, the information in the tables below apply to both Eligibility and Eligibility for Pharmacy.

Elements that are grouped together may be marked as mandatory; however, if the group itself is marked as conditional or recommended, then these are only required if you use the group.

Requirement Designation

Code	Description
mandatory	The element must be used per the specification (e.g., XML schema validation). Note: The term mandatory applies to mandatory and required fields in the different standards.
business rule	If sent, the element must be used per the Surescripts business rule. Note: Not all business rules reside in this table.
conditional	The element is to be used per the conditions specified. Note: The term conditional applies to conditional and situational fields in the different standards. For example, X12 uses the term situational.
recommended	Surescripts recommends sending the element as a best practice.
optional	Some fields do not have specific conditions. Data should be sent if available.
not used	Not used by Surescripts.

Header

Segment ID (Eligibility Response)	Segment Name (Eligibility Response)	Code	Comments
ISA	Interchange Control Header	mandatory
ISA01	Authorization Information Qualifier	mandatory	Value: 00 - No Authorization Information Present (No Meaningful Information in I02)
ISA02	Authorization Number	mandatory	Not used. Fill with blanks.
ISA03	Security Information Qualifier	mandatory	Code to identify the type of information in the Security Information. Value: 01 - Password
ISA04	Security Information	mandatory	From the PBM/payer to Surescripts, this is the Surescripts system assigned password to the PBM/payer. From Surescripts, this is the password Surescripts uses when sending to the provider vendor.
ISA05	Interchange ID Qualifier	mandatory	Qualifier ZZ - Mutually Defined
ISA06	Interchange Sender ID	mandatory	From the PBM/payer to Surescripts, this is the PBM/payer's Participant ID. From Surescripts to the provider vendor system, this is Surescripts’ ID.
ISA07	Interchange ID Qualifier	mandatory	Qualifier ZZ - Mutually Defined
ISA08	Interchange Receiver ID	mandatory	From the PBM/payer, this is Surescripts’ ID. From Surescripts to the provider vendor system, this is the provider vendor’s Participant ID.
ISA09	Interchange Date	mandatory	Date format YYMMDD required.
ISA10	Interchange Time	mandatory	Time format HHMM required.
ISA11	Repetition Separator	mandatory	Surescripts recommends using Hex 1F.
ISA12	Interchange Control Version Number	mandatory	This version number covers the interchange control segments. 00501 – Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA13	Interchange Control Number	mandatory	From the PBM/payer, this is the PBM/payer's unique identification of this transaction. From Surescripts, this is Surescripts’ unique identification of this transaction. This number is returned on a TA1 if an error occurs. Providing a unique number will assist in resolving errors and tracking messages.
ISA14	Acknowledgement Requested	mandatory	The TA1 segment will only be transmitted in the event of a header or trailer ERROR. TA1 segments should not be returned for accepted transactions. If there are no errors at the envelope level (ISA, GS, GE, IEA segments) then TA1 segments should not be returned. Since these transactions are real time only, Surescripts does not use this field to determine whether to create a TA1 acknowledgment.
ISA15	Interchange Usage Indicator	mandatory	Values P - Production Data T - Test Data
ISA16	Component Element Separator	mandatory	Surescripts recommends using Hex IC.
GS	Functional Group Header	mandatory
GS01	Functional Identifier Code	mandatory	Value: HB
GS02	Application Sender’s Code	mandatory	From the PBM/payer to Surescripts, this is the PBM/payer's Participant ID. From Surescripts to the provider vendor system, this is Surescripts’ ID.
GS03	Application Receiver’s Code	mandatory	From the PBM/payer to Surescripts, this is Surescripts’ ID. From Surescripts to the provider vendor system, this is the provider vendor’s Participant ID.
GS06	Group Control Number	mandatory	The control number should be unique across all functional groups within this transaction set. This number is returned on an AK102 of the 999 acknowledgment if an error occurs. Providing a unique number will assist in resolving errors and tracking messages.
ST	Transaction Set Header	mandatory
ST02	Transaction Set Control Number	mandatory	This ID will be returned on an AK202 of the 999 acknowledgment if an error occurs. Providing a unique number will assist in resolving errors and tracking messages.
BHT	Beginning of Hierarchical Transaction	mandatory
BHT03	Reference Identification	mandatory	Because this Implementation is Real Time, this number from the Eligibility Request is to be returned in this field.

Detail

Segment ID (Eligibility Response)	Segment Name (Eligibility Response)	Code	Comments
Loop ID – 2000A Information Source Level
HL	Information Source Level (PBM/payer)	mandatory
AAA	Request Validation	conditional
AAA03	Reject Reason Code	mandatory	Value: 42 - Unable to Respond at Current Time Note: Surescripts could not process the transaction.
Loop ID – 2100A Information Source Name
NM1	Information Source Name	mandatory
NM101	Entity Identifier Code	mandatory	Value: 2B - Third-Party Administrator (Recommended by Surescripts)
NM102	Entity Type Qualifier	mandatory	Value: 2 - Non-Person Entity (Recommended by Surescripts)
NM103	Organization Name	mandatory	This is the name of the PBM/payer that provides the data. It does not include Surescripts at any point.
NM108	Identification Code Qualifier	mandatory	Surescripts will utilize PI to identify the Payer (the PBM/payer). Value: PI - Payer Identification (Recommended by Surescripts)
NM109	Identification Code	mandatory	This is the PBM/payer’s Participant ID.
AAA	Request Validation	conditional
AAA03	Reject Reason Code	mandatory	Values: 41 - Authorization/Access Restrictions To the provider vendor system from Surescripts, 41 would indicate that the provider vendor system cannot request transactions for the identified PBM/payer. To Surescripts from the PBM/payer, 41 would indicate that Surescripts cannot request eligibility from this PBM/payer. 42 - Unable to Respond at Current Time PBM/payer cannot process at current time. 79 - Invalid Participant Identification The PBM/payer will use this code to indicate that Information Source Identified in Loop 2100A is invalid.
Loop ID – 2000B Information Receiver Level
HL	Information Receiver Level (Physician)	conditional
Loop ID – 2100B Information Receiver Name
NM1	Information Receiver Name	mandatory
NM101	Entity Identifier Code	mandatory	Value: 1P - Provider (Recommended by Surescripts)
NM102	Entity Type Qualifier	mandatory	Value: 1 - Person (Recommended by Surescripts)
NM108	Identification Code Qualifier	mandatory	Qualifier: XX - Centers for Medicare and Medicaid Services National Provider Identifier.
NM109	Identification Code	mandatory	The NPI is mandated. Surescripts will reject if the NM108 and the NM109 are not populated.
REF	Information Receiver Additional Identification (Provider Vendor System Identification)	recommended	Surescripts defined Participant ID for the provider vendor system.
REF01	Reference Identification Qualifier	mandatory	Value: EO - Submitter Identification Number (A unique number identifying the submitter of the transaction set.)
REF02	Reference Identification	mandatory	Surescripts defined Participant ID for the provider vendor system.
REF03	Description	conditional	Not used for the EO qualifier.
AAA	Information Receiver Request Validation	conditional
AAA03	Reject Reason Code	mandatory	Values: 15 - Required application data missing Use this code only when the information receiver’s additional identification is missing. (Not enough information given to identify the provider vendor system.) 41 - Authorization/Access Restrictions (A contract does not exist between this provider vendor system and the PBM/payer to exchange eligibility information.) 43 - Invalid/Missing Provider Identification (If there is an NPI error, Surescripts will send an error stating NPI is not valid.) 79 - Invalid Participant Identification. (Surescripts cannot validate the receiver.)
Loop ID – 2000C Subscriber Level
HL	Subscriber Level	conditional
TRN	Subscriber Trace Number	conditional	Echo the trace number back from the Eligibility Request in this field.
Loop ID – 2100C Subscriber Name
NM1	Subscriber Name	mandatory
NM103	Name Last	conditional	This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request.
NM104	Name First	conditional	This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request.
NM105	Name Middle	conditional	This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request.
NM107	Name Suffix	conditional	This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request.
NM108	Identification Code Qualifier	conditional	Value: MI - Member Identification Number
NM109	Identification Code	conditional	Subscriber PBM Unique Member ID. Send the full PBM Unique Member ID.
REF	Subscriber Additional Identification (Person Code, Cardholder ID, SSN, Patient Account Number)	recommended
REF01	Reference Identification Qualifier	mandatory	Value: HJ - Identity Card Number (Cardholder ID) Strongly recommended by Surescripts. 49 - Family Unit Member (Person Code) SY - Social Security Number Recommended to not send social security number. Social security number may not be used for any federally administered programs such as Medicare. EJ - Patient Account Number Echo the patient account number back from the Eligibility Request in this field.
N3	Subscriber Address	conditional
N301	Address Information	mandatory	This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request.
N302	Address Information	conditional	This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request.
N4	Subscriber City/State/ZIP Code	conditional	Required to be sent when patient is the subscriber.
N401	City Name	mandatory	This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request.
N402	State or Province Code	conditional	This field is required if City Name (N401) is in the U.S. or Canada. This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request.
N403	Postal Code	conditional	This field is required if City Name (N401) is in the U.S. or Canada. This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request.
N404	Country Code	conditional	Do not send US Country Code.
AAA	Subscriber Request Validation	conditional
AAA03	Reject Reason Code	mandatory	Values: 15 - Required application data missing At Surescripts – Not enough information for Surescripts to identify patient. At PBM/payer – Wants more information than what was supplied. 62 - Service Date Invalid Sent if service date is greater than 3 days in the past or future of the transmission date of the message.
DMG	Subscriber Demographic Information	conditional
DMG02	Date Time Period	conditional	This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request.
DMG03	Gender Code	conditional	This data is to be returned from the PBM/payer system, and should not be echoed back from the Eligibility Request. Values: M – Male F – Female U – Unknown or other
INS	Subscriber Relationship	conditional
INS01	Yes/No Condition or Response Code	mandatory	For the provider vendor system, this will always be Yes (Y), if supplied.
INS02	Individual Relationship Code	mandatory	For the provider vendor system, this will always be Self (18).
INS03	Maintenance Type Code	conditional	Code identifying the reason for the maintenance change. Use this element (and code “25” in INS04) if any of the identifying elements for the subscriber have been changed from those submitted in the Eligibility Request. Value: 001 - Change
INS04	Maintenance Reason Code	conditional	Code identifying the reason for the maintenance change. Use this element (and code “001” in INS03) if any of the identifying elements for the subscriber have been changed from those submitted in the Eligibility Request. Value: 25 - Change in Identifying Data Elements Use this code to indicate that a change has been made to the primary elements that identify a specific person. Such elements include but are not limited to first name, last name, patient gender, date of birth, and address.
DTP	Subscriber Date	conditional
DTP02	Date Time Period Format Qualifier	mandatory	Value: D8 - Date Expressed in Format CCYYMMDD (Surescripts recommends D8.)
Loop ID – 2110C Subscriber Eligibility or Benefit Information
EB	Subscriber Eligibility or Benefit Information.	recommended	This segment indicates active and inactive coverage. If the first iteration of the EB loop is set to “1” (Active), then use subsequent EB loops for retail, for mail order, and optionally, for specialty pharmacy and/or LTC. If the EB loop is set to “6” (Inactive), then no other EB loops are required.
EB01	Eligibility or Benefit Information	mandatory	Code identifying eligibility or benefit information. Values: 1 - Active Coverage 6 - Inactive If the member is inactive, then no other EB loops are required to be sent. V - Cannot Process G - Out of Pocket (Stop Loss) I - Non-covered
EB03	Service Type Code	conditional	The EB loop repeats. A value of “30” is sent in first iteration of the EB loop to determine if coverage is active. For active coverage: it is required to send subsequent EB 2110C loops for retail and for mail order subsequent 2110C loops may also be sent for specialty pharmacy and/or LTC For inactive coverage, then no other EB loops are required. See ACR E.103 in Application Certification RequirementsApplication Certification Requirements for more information. Values: 30 - Health Plan Benefit Coverage 88 - Pharmacy (Retail Benefit) 90 - Mail Order Prescription Drug Empty/Null - Specialty Pharmacy or LTC (See MSG.)
EB04	Insurance Type Code	recommended	Indicates type of insurance. Example values include but are not limited to: C1 – Commercial MA – Medicare Part A MC - Medicaid OT – Medicare Part D WC – Workers Comp
EB05	Plan Coverage Description	conditional	If EB03 contains 30 (Active), then EB05 will contain the primary health plan name, if applicable. If sent, Surescripts requires applications to display this for prescribers and pharmacists. See ACR E.103 in Application Certification RequirementsApplication Certification Requirements for more information.
EB07	Monetary Amount	conditional	Surescripts is utilizing this field for Out of Pocket Accumulator. EB01 set to G.
REF	Subscriber Additional Identification (Plan ID, Group ID/Name, Formulary ID, Alternative ID, Coverage List ID, IIN/PCN, and Copay ID)	conditional	When available, it is required that the PBM/Payer sends IIN/PCN/Group ID/Group Name/Plan ID and formulary file IDs. When this information is included on the Eligibility Response, the provider is able to select the most appropriate coverage for the patient and it is populated by the provider vendor downstream on Prior Authorization, Real-Time Prescription Benefit, and NewRx transactions. See ACR E.106.1 in the Application Certification RequirementsApplication Certification Requirements for more information. IIN Note: Per NCPDP, since 8-digit IINs are now being assigned, use the first 6 digits of the IIN as the BIN even if the first digit(s) is a zero. Once new version of the NCPDP Telecommunication Standard is adopted new, truncation will no longer be necessary. Refer to NCPDP - IIN/Processor Identification Number (Processor BIN) Use - NCPDP Processor ID (BIN) for more information.
REF01	Code Qualifying the Reference Identification	mandatory	Values: 18 - Plan ID 6P - Group Number and Group Name ALS - Alternative List ID CLI - Coverage List ID FO - Drug Formulary Number ID IG - Insurance Policy Number (Copay ID) N6 - Plan Network ID (IIN/PCN) (Strongly recommended by Surescripts.)
REF02	Reference Identification	mandatory	Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier. Use this information for the reference number as qualified by the preceding data element (REF01). Note: Group number (6P) refers to the prescription benefit coverage Group ID (which is typically 15 characters or less), not the Member Plan Group ID Number that refers to Medical, Dental, etc. coverage.
REF03	Description	recommended	Sending this element is strongly recommended by Surescripts and should only be used for Group Name and/or PCN number. REF01=6P (REF03 will contain group name.) REF01=N6 (REF03 will contain PCN Number.)
DTP	Subscriber Eligibility/Benefit Date	conditional	Surescripts recommends sending back the date range of the health plan benefit for this patient’s coverage.
DTP02	Date Time Period Format Qualifier	mandatory	Value: RD8 - Range of Dates expressed in Format CCYYMMDD-CCYYMMDD (Surescripts recommends RD8.)
AAA	Subscriber Request Validation	conditional
MSG	Message Text	conditional
MSG01	Free-Form Message Text	mandatory	This free text field is used to communicate Specialty Pharmacy or Long-Term Care coverage and will be populated by Surescripts as a hint to the requester on what fields would assist in identifying the patient. This is sent if patient is not found and one or more of the following fields are missing; first name, last name, zip code or date of birth.
Loop ID – 2115C Subscriber Eligibility or Benefit Additional Information
LS	Loop Header	conditional
Loop ID – 2120C Subscriber Benefit Related Entity Name
NM1	Subscriber Benefit Related Entity Name	recommended	This segment is used for Mail Only Benefit, Long-Term Care, and determining primary, secondary, and tertiary Eligibility coverages. Example of secondary coverage: NM1SEP2PBM COMPANY***PIPBM123~
NM101	Entity Identifier Code	mandatory	Code identifying an organization entity, a physical location, a property, or an individual. Values: 13 - Contracted Service Provider (Use for Mail Only Benefit. Used to further clarify benefits, including Mail Only, Specialty and Long Term Care.) PRP – Primary Payer SEP – Secondary Payer TTP – Tertiary Payer
NM102	Entity Type Qualifier	mandatory	Value: 2 - Non-Person Entity (Surescripts recommends using 2)
NM108	Identification Code Qualifier	conditional	Value: SV - Service Provider Number (Recommended by Surescripts) PI – Payer Identification (Surescripts Assigned ID) Use this code for the identification number assigned by the information source.
LE	Loop Trailer	conditional

Trailer

Segment ID (Eligibility Response)	Segment Name (Eligibility Response)	Code
SE	Transaction Set Trailer	mandatory
GE	Functional Group Trailer	mandatory
IEA	Interchange Control Trailer	mandatory

TA1 Interchange Acknowledgement

Requirement Designation

Code	Description
mandatory	The element must be used per the specification (e.g., XML schema validation). Note: The term mandatory applies to mandatory and required fields in the different standards.
business rule	If sent, the element must be used per the Surescripts business rule. Note: Not all business rules reside in this table.
conditional	The element is to be used per the conditions specified. Note: The term conditional applies to conditional and situational fields in the different standards. For example, X12 uses the term situational.
recommended	Surescripts recommends sending the element as a best practice.
optional	Some fields do not have specific conditions. Data should be sent if available.
not used	Not used by Surescripts.

ICS Interchange Control Structures

The purpose of this standard is to define the control structures for the electronic interchange of one or more encoded business transactions including the EDI (Electronic Data Interchange) encoded transactions of Accredited Standards Committee X12. This standard provides the interchange envelope of a header and trailer for the electronic interchange through a data transmission, and it provides a structure to acknowledge the receipt and processing of this envelope.

Notes:

This guide only includes data elements where Surescripts has specific requirements or further explains the field usage. Refer to ASC X12N/005010X231A1 Implementation Acknowledgement for Health Care Insurance (999) for a complete list of segments and elements. In addition, comments below where codes are specified are either to call out Surescripts notes and/or to show the code recommended by Surescripts. For a full list of codes, please refer to ASC X12N/005010X231A1 Implementation Acknowledgement for Health Care Insurance (999).

Unless specified otherwise, the information in the tables below apply to both Eligibility and Eligibility for Pharmacy.

Elements that are grouped together may be marked as mandatory; however, if the group itself is marked as conditional or recommended, then these are only required if you use the group.

Segment ID (TA1)	Segment Name (TA1)	Code	Comments
ISA	Interchange Control Header	mandatory
ISA01	Authorization Information Qualifier	mandatory	Value: 00 - No Authorization Information Present (No Meaningful Information in I02)
ISA02	Authorization Information	mandatory	Not used. Fill with blanks.
ISA03	Security Information Qualifier	mandatory	Code to identify the type of information in the Security Information. Value: 01 - Password
ISA04	Security Information	mandatory	Password utilized by the sender to access the receiver system.
ISA05	Interchange ID Qualifier	mandatory	Qualifier ZZ - Mutually Defined
ISA06	Interchange Sender ID	mandatory	The Sender Participant ID. Participant ID is the Surescripts system Participant ID.
ISA07	Interchange ID Qualifier	mandatory	Qualifier ZZ - Mutually Defined
ISA08	Interchange Receiver ID	mandatory	The Receiver Participant ID. Participant ID is assigned by Surescripts.
ISA09	Interchange Date	mandatory	Date format YYMMDD required.
ISA10	Interchange Time	mandatory	Time format HHMM required.
ISA11	Repetition Separator	mandatory	Surescripts recommends using Hex 1F.
ISA12	Interchange Control Version Number	mandatory	This version number covers the interchange control segments. 00501 – Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA13	Interchange Control Number	mandatory	A unique number assigned by the sender. Used to communicate from the receiver back to the sender to identify this transaction.
ISA14	Acknowledgment Requested	mandatory	No TA1s are returned for TA1s.
ISA15	Interchange Usage Indicator	mandatory	Values: P - Production Data T - Test Data
ISA16	Component Element Separator	mandatory	Surescripts recommends using Hex 1C.
TA1	Interchange Acknowledgment	conditional	Surescripts only supports the TA1 for errors. It is not sent as an acknowledgment for successful messages.
IEA	Interchange Control Trailer	mandatory

999 Implementation Acknowledgement for Health Care Insurance

Notes:

This guide only includes data elements where Surescripts has specific requirements or further explains the field usage. Refer to ASC X12N/005010X231A1 Implementation Acknowledgement for Health Care Insurance (999) for a complete list of segments and elements. In addition, comments below where codes are specified are either to call out Surescripts notes and/or to show the code recommended by Surescripts. For a full list of codes, please refer to ASC X12N/005010X231A1 Implementation Acknowledgement for Health Care Insurance (999).

Unless specified otherwise, the information in the tables below apply to both Eligibility and Eligibility for Pharmacy.

Elements that are grouped together may be marked as mandatory; however, if the group itself is marked as conditional or recommended, then these are only required if you use the group.

Requirement Designation

Code	Description
mandatory	The element must be used per the specification (e.g., XML schema validation). Note: The term mandatory applies to mandatory and required fields in the different standards.
business rule	If sent, the element must be used per the Surescripts business rule. Note: Not all business rules reside in this table.
conditional	The element is to be used per the conditions specified. Note: The term conditional applies to conditional and situational fields in the different standards. For example, X12 uses the term situational.
recommended	Surescripts recommends sending the element as a best practice.
optional	Some fields do not have specific conditions. Data should be sent if available.
not used	Not used by Surescripts.

Header

Segment ID(999)	Segment Name(999)	Code	Comments
ISA	Interchange Control Header	mandatory
ISA01	Authorization Information Qualifier	mandatory	Value: 00 - No Authorization Information Present (No Meaningful Information in I02)
ISA02	Authorization Number	mandatory	Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01).
ISA03	Security Information Qualifier	mandatory	Code to identify the type of information in the Security Information Value: 01 - Password
ISA04	Security Information	mandatory	Password used by the sender to access the receiver system. Password assigned by Surescripts.
ISA05	Interchange ID Qualifier	mandatory	Qualifier ZZ - Mutually Defined
ISA06	Interchange Sender ID	mandatory	From Surescripts to the PBM/payer, this is Surescripts’ ID.
ISA07	Interchange ID Qualifier	mandatory	Qualifier ZZ - Mutually Defined
ISA08	Interchange Receiver ID	mandatory	The Receiver Participant ID. Participant ID is assigned by Surescripts.
ISA09	Interchange Date	mandatory	Date format YYMMDD required.
ISA10	Interchange Time	mandatory	Time format HHDD required.
ISA11	Repetition Separator	mandatory	Surescripts recommends using Hex 1F.
ISA12	Interchange Control Version Number	mandatory	This version number covers the interchange control segments. 00501 – Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA13	Interchange Control Number	mandatory	The sender’s unique identification of this transaction.
ISA14	Acknowledgment Requested	mandatory	No TA1s are returned for 999s.
ISA15	Interchange Usage Indicator	mandatory	Values P - Production Data T - Test Data
ISA16	Component Element Separator	mandatory	Surescripts recommends using Hex 1C.
GS	Functional Group Header	mandatory
GS02	Application Sender’s Code	mandatory	The Sender Participant ID. Participant ID is assigned by Surescripts.
GS03	Application Receiver’s Code	mandatory	The Receiver Participant ID. Participant ID is assigned by Surescripts.
GS08	Version / Release / Industry Identifier Code	mandatory	Value: 005010X231A1
ST	Transaction Set Header	mandatory
AK1	Functional Group Response Header	mandatory
Loop ID - 2000 - AK2 Transaction Set Response Header
AK2	Transaction Set Response Header	conditional
AK203	Implementation Convention Reference	conditional	Required when the ST03 value is available in the transaction set to which this 999 transaction set is responding. Since ST03 is required the AK203 must be present
Loop ID - 2100 - AK2/IK3 Error Identification
IK3	Error Identification	conditional
CTX	Segment Context	conditional
CTX	Business Unit Identifier	conditional
Loop ID - 2110 - AK2/IK3/IK4 Implementation Data Element Note
IK4	Implementation Data Element Note	conditional
CTX	Element Context	conditional
IK5	Transaction Set Response Trailer	mandatory
IK501	Transaction Set Acknowledgment Code	mandatory	Value: R - Rejected (Surescripts recommends R.)
AK9	Functional Group Response Trailer	mandatory
AK901	Functional Group Acknowledgment Code	mandatory	Value: R - Rejected (Surescripts recommends use of R.)

Trailer

Segment ID (999)	Segment Name (999)	Code
SE	Transaction Set Trailer	mandatory
GE	Functional Group Trailer	mandatory
IEA	Interchange Control Trailer	mandatory

Hierarchical Loops

Eligibility Request Hierarchical Organization

The diagram below depicts the hierarchical organization of all loops and includes those related specifically to the EQ segment.

Eligibility Response Hierarchical Organization

The diagram below depicts the hierarchical organization of all loops and includes those related specifically to the EB segments.