Eligibility Request and Response Message Examples

this is an example of a prescriber/clinic checking a patient’s benefit plan the lifecycle consists of provider vendor creates eligibility request and sends to surescripts surescripts identifies the patient and sends eligibility request to the pbm/payer the pbm/payer processes the eligibility request and returns eligibility response to surescripts surescripts returns eligibility response to the provider vendor notes examples provided throughout this guide are not intended to be all inclusive this pertains to example workflows, element specific (field) examples, or message examples customers should not restrict coding to the examples used herein in the transaction examples, line breaks are used at the end of the segments for illustrative purposes; however, it is recommended to not use line breaks in live transactions refer to appendix b dynamic delimiters for a full list of characters that are acceptable to use as delimiters eligibility request (from provider vendor to surescripts) example isa 00 01 pwphy12345 zz p01234567891234 zz s00000000000001 171217 0309 ^ 00501 000000001 0 p \[ element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id p01234567891234 provider vendor’s participant id isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id s00000000000001 participant id for surescripts isa09 interchange date 171217 date isa10 interchange time 0309 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs hs p01234567891234 s00000000000001 20171217 16150000 1 x 005010x279a1 element element name value note gs01 functional identifier code hs functional identifier code gs02 application sender’s code p01234567891234 participant's id gs03 application receiver’s code s00000000000001 surescripts id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st 270 0001 005010x279a1 element element name value note st01 transaction set identifier code 270 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht 0022 13 3920394930203 20171217 16150000 element element name value note bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 13 indicates purpose of transaction set (value 13 = request) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl 1 20 1 element element name value note hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) nm1 2b 2 surescripts llc pi s00000000000001 element element name value note hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name surescripts llc source does not know pbm/payer so they put in surescripts hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code s00000000000001 surescripts id hl 2 1 21 1 element element name value note hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) nm1 1p 1 jonson tim t m d xx 3334444555 element element name value note hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl2\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref eo p01234567891234 element element name value note ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number n3 55 high street element element name value note n301 address information 55 high street address information n4 seattle wa 98123 element element name value note n401 city name seattle city name n402 state or province code wa state n403 postal code 98123 postal code (zip code) hl 3 2 22 0 element element name value note hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure nm1 il 1 cross david m element element name value note hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient n3 6785 laughalot lane element element name value note n301 address information 6785 laughalot lane address information n4 trenton nj 08608 element element name value note n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg d8 19720910 m element element name value note dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 date time period dmg03 gender code m gender code (value m = male) dtp 291 d8 20171217 element element name value note dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dtp03 date time period 20171217 eq 30 element element name value note eq01 service type code 30 health plan benefit coverage se 17 0001 element element name value note se01 number of included segments 17 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge 1 1 element element name value note ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea 1 000000001 element element name value note iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number eligibility request (from provider vendor to surescripts) full example table full example table element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id p01234567891234 provider vendor’s participant id isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id s00000000000001 participant id for surescripts isa09 interchange date 171217 date isa10 interchange time 0309 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs01 functional identifier code hs functional identifier code gs02 application sender’s code p01234567891234 participant's id gs03 application receiver’s code s00000000000001 surescripts id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st01 transaction set identifier code 270 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 13 indicates purpose of transaction set (value 13 = request) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name surescripts llc source does not know pbm/payer so they put in surescripts hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code s00000000000001 surescripts id hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl2\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number n301 address information 55 high street address information n401 city name seattle city name n402 state or province code wa state n403 postal code 98123 postal code (zip code) hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient n301 address information 6785 laughalot lane address information n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 date time period dmg03 gender code m gender code (value m = male) dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dtp03 date time period 20171217 date time period eq01 service type code 30 health plan benefit coverage se01 number of included segments 17 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number eligibility request (from surescripts to pbm/payer) example note surescripts has located the patient and populated the pbm unique member id isa 00 01 pw12345pbm zz s00000000000001 zz pbm123456789123 171217 0309 ^ 00501 000000001 0 p \[ element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id p01234567891234 provider vendor’s participant id isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id s00000000000001 participant id for surescripts isa09 interchange date 171217 date isa10 interchange time 0309 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs hs p01234567891234 s00000000000001 20171217 16150000 1 x 005010x279a1 element element name value note gs01 functional identifier code hs functional identifier code gs02 application sender’s code p01234567891234 participant's id gs03 application receiver’s code s00000000000001 surescripts id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st 270 0001 005010x279a1 element element name value note st01 transaction set identifier code 270 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht 0022 13 3920394930203 20171217 16150000 element element name value note bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 13 indicates purpose of transaction set (value 13 = request) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl 1 20 1 element element name value note hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) nm1 2b 2 surescripts llc pi s00000000000001 element element name value note hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name surescripts llc source does not know pbm/payer so they put in surescripts hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code s00000000000001 surescripts id hl 2 1 21 1 element element name value note hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) nm1 1p 1 jonson tim t m d xx 3334444555 element element name value note hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl2\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref eo p01234567891234 element element name value note ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number n3 55 high street element element name value note n301 address information 55 high street address information n4 seattle wa 98123 element element name value note n401 city name seattle city name n402 state or province code wa state n403 postal code 98123 postal code (zip code) hl 3 2 22 0 element element name value note hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure nm1 il 1 cross david m element element name value note hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient n3 6785 laughalot lane element element name value note n301 address information 6785 laughalot lane address information n4 trenton nj 08608 element element name value note n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg d8 19720910 m element element name value note dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 date time period dmg03 gender code m gender code (value m = male) dtp 291 d8 20171217 element element name value note dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dtp03 date time period 20171217 date time period eq 30 element element name value note eq01 service type code 30 health plan benefit coverage se 17 0001 element element name value note se01 number of included segments 17 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge 1 1 element element name value note ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea 1 000000001 element element name value note iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number eligibility request (from provider vendor to surescripts) full example table full example table element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id p01234567891234 provider vendor’s participant id isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id s00000000000001 participant id for surescripts isa09 interchange date 171217 date isa10 interchange time 0309 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs01 functional identifier code hs functional identifier code gs02 application sender’s code p01234567891234 participant's id gs03 application receiver’s code s00000000000001 surescripts id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st01 transaction set identifier code 270 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 13 indicates purpose of transaction set (value 13 = request) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name surescripts llc source does not know pbm/payer so they put in surescripts hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code s00000000000001 surescripts id hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl2\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number n301 address information 55 high street address information n401 city name seattle city name n402 state or province code wa state n403 postal code 98123 postal code (zip code) hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient n301 address information 6785 laughalot lane address information n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 date time period dmg03 gender code m gender code (value m = male) dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dtp03 date time period 20171217 date time period eq01 service type code 30 health plan benefit coverage se01 number of included segments 17 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number eligibility request (from surescripts to pbm/payer) full example table full example table element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pw12345pbm password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id s00000000000001 participant id for surescripts isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id pbm123456789123 pbm/payer participant id isa09 interchange date 171217 date isa10 interchange time 0309 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 10 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs01 functional identifier code hs functional identifier code gs02 application sender’s code s00000000000001 surescripts id gs03 application receiver’s code pbm123456789123 pbm/payer participant id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st01 transaction set identifier code 270 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 13 indicates purpose of transaction set (value 13 = request) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name pbm company pbm/payer hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code pbm123456789123 pbm/payer participant id hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl2\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number n301 address information 55 high street address information n401 city name seattle city name n402 state or province code wa state n403 postal code 98123 postal code (zip code) hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient hl3\ nm108 identification code qualifier mi value mi = member identification number hl3\ nm109 identification code dd145645645601 identification code identifying the patient n301 address information 6785 laughalot lane address information n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 date time period dmg03 gender code m gender code (value m = male) dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dtp03 date time period 20171217 date time period eq01 service type code 30 health plan benefit coverage se01 number of included segments 17 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number eligibility response (from pbm/payer to surescripts) example isa 00 01 pwphy12345 zz pbm123456789123 zz s00000000000001 171217 0345 ^ 00501 000000001 1 p \[ element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id pbm123456789123 pbm/payer participant id isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id s00000000000001 participant id for surescripts isa09 interchange date 171217 date isa10 interchange time 0345 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs hb pbm123456789123 s00000000000001 20171217 16150000 1 x 005010x279a1 element element name value note gs01 functional identifier code hb functional identifier code gs02 application sender’s code pbm123456789123 pbm/payer participant id gs03 application receiver’s code s00000000000001 surescripts id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st 271 0001 005010x279a1 element element name value note st01 transaction set identifier code 271 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht 0022 11 3920394930203 20171217 16150000 element element name value note bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 11 indicates purpose of transaction set (value 11 = response) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl 1 20 1 element element name value note hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) nm1 2b 2 pbm company pi pbm123456789123 element element name value note hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name pbm company pbm/payer hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code pbm123456789123 pbm/payer participant id hl 2 1 21 1 element element name value note hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) nm1 1p 1 jonson tim t m d xx 3334444555 element element name value note hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl3\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref eo p01234567891234 element element name value note ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number hl 3 2 22 0 element element name value note hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure nm1 il 1 cross david m mi dd145645645601 element element name value note hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient hl3\ nm108 identification code qualifier mi value mi = member identification number hl3\ nm109 identification code dd145645645601 identification code identifying the patient ref 49 01 element element name value note ref01 reference identification qualifier 49 value 49 = family unit number note required when the information source is a pbm/payer and the individual has a suffix to their member id number that is required for use in the ncpdp standard (for person code) ref02 reference identification 01 family unit number (person code) n3 6785 laughalot lane element element name value note n301 address information 6785 laughalot lane address information n4 trenton nj 08608 element element name value note n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg d8 19720910 m element element name value note dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 patient date of birth dmg03 gender code m gender code (value m = male) ins y 18 element element name value note ins01 yes/no condition or response code y yes/no condition or response code value y = yes ins02 individual relationship code 18 individual relationship code value 18 = self dtp 291 d8 20171217 element element name value note dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dtp03 date time period 20171217 date time period eb 1 30 mc medicaidplan element element name value note eb01 eligibility or benefit information code 1 value 1 = active coverage eb03 coverage level code 30 value 30 = health plan benefit coverage eb04 insurance type code mc value mc = medicaid eb05 service type code medicaidplan health plan name ref 6p dd1 abcgroup element element name value note ref01 reference identification qualifier 6p value 6p = group number ref02 reference identification dd1 group number ref03 description abcgroup group name ref fo 201 element element name value note ref01 reference identification qualifier fo value fo = drug formulary number ref02 reference identification 201 drug formulary number ref cli 201 element element name value note ref01 reference identification qualifier cli value cli = coverage list id ref02 reference identification 201 coverage list id ref n6 234876 av element element name value note ref01 reference identification qualifier n6 value n6 = plan network identification number ref02 reference identification 234876 iin (formerly known as bin) ref03 description av pcn ref ig 201 element element name value note ref01 reference identification qualifier ig value ig = insurance policy number ref02 reference identification 201 copay list id ref als 142345 element element name value note ref01 reference identification qualifier als value als = alternative list id ref02 reference identification 142345 alternative list id dtp 291 rd8 20100801 20991231 element element name value note dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier rd8 date time period format qualifier (range of dates expressed in format ccyymmdd ccyymmdd) dtp03 date time period 20100801 20991231 date time period ls 2120 element element name value note ls01 loop identifier code 2120 loop header nm1 sep 2 pbm company pi pbm123456789123 element element name value note hl4\ nm101 entity identifier code sep this field is used to show the primary coverage level value sep = secondary payer hl4\ nm102 entity type qualifier 2 non person entity hl4\ nm103 name last or organization name pbm company pbm/payer hl4\ nm108 identification code qualifier pi value pi = payor identification hl4\ nm109 identification code pbm123456789123 pbm/payer participant id le 2110 element element name value note le01 loop identifier code 2110 loop trailer eb 1 88 element element name value note eb01 eligibility or benefit information code 1 value 1 = active coverage eb03 coverage level code 88 value 88 = pharmacy (retail pharmacy) eb 1 90 element element name value note eb01 eligibility or benefit information code 1 value 1 = active coverage eb03 coverage level code 90 value 90 = mail order prescription drug (mail order pharmacy) se 29 0001 element element name value note se01 number of included segments 29 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge 1 1 element element name value note ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea 1 000000001 element element name value note iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number eligibility response (from pbm/payer to surescripts) full example table full example table element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id pbm123456789123 pbm/payer's participant id isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id s00000000000001 participant id for surescripts isa09 interchange date 171217 date isa10 interchange time 0345 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs01 functional identifier code hb functional identifier code gs02 application sender’s code pbm123456789123 pbm/payer participant id gs03 application receiver’s code s00000000000001 surescripts id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st01 transaction set identifier code 271 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 11 indicates purpose of transaction set (value 11 = response) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name pbm company pbm/payer hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code pbm123456789123 pbm/payer participant id hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl3\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient hl3\ nm108 identification code qualifier mi value mi = member identification number hl3\ nm109 identification code dd145645645601 identification code identifying the patient ref01 reference identification qualifier 49 value 49 = family unit number note required when the information source is a pbm/payer and the individual has a suffix to their member id number that is required for use in the ncpdp standard (for person code) ref02 reference identification 01 family unit number (person code) n301 address information 6785 laughalot lane address information n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 patient date of birth dmg03 gender code m gender code (value m = male) ins01 yes/no condition or response code y yes/no condition or response code value y = yes ins02 individual relationship code 18 individual relationship code value 18 = self dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dtp03 date time period 20171217 date time period eb01 eligibility or benefit information code 1 value 1 = active coverage eb03 coverage level code 30 value 30 = health plan benefit coverage eb04 insurance type code mc value mc = medicaid eb05 service type code medicaidplan health plan name ref01 reference identification qualifier 6p value 6p = group number ref02 reference identification dd1 group number ref03 description abcgroup group name ref01 reference identification qualifier fo value fo = drug formulary number ref02 reference identification 201 drug formulary number ref01 reference identification qualifier cli value cli = coverage list id ref02 reference identification 201 coverage list id ref01 reference identification qualifier n6 value n6 = plan network identification number ref02 reference identification 234876 iin (formerly known as bin) ref03 description av pcn ref01 reference identification qualifier ig value ig = insurance policy number ref02 reference identification 201 copay list id ref01 reference identification qualifier als value als = alternative list id ref02 reference identification 142345 alternative list id dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier rd8 date time period format qualifier (range of dates expressed in format ccyymmdd ccyymmdd) dtp03 date time period 20100801 20991231 date time period ls01 loop identifier code 2120 loop header hl4\ nm101 entity identifier code sep this field is used to show the primary coverage level value sep = secondary payer hl4\ nm102 entity type qualifier 2 non person entity hl4\ nm103 name last or organization name pbm company pbm/payer hl4\ nm108 identification code qualifier pi value pi = payor identification hl4\ nm109 identification code pbm123456789123 pbm/payer participant id le01 loop identifier code 2110 loop trailer eb01 eligibility or benefit information code 1 value 1 = active coverage eb03 coverage level code 88 value 88 = pharmacy (retail pharmacy) eb01 eligibility or benefit information code 1 value 1 = active coverage eb03 coverage level code 90 value 90 = mail order prescription drug (mail order pharmacy) se01 number of included segments 29 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number eligibility response (from surescripts to provider vendor) example isa 00 01 pw12345phy zz s00000000000001 zz p01234567891234 171217 0345 ^ 00501 000000001 0 p \[ element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id s00000000000001 participant id for surescripts isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id p01234567891234 provider vendor’s participant id isa09 interchange date 171217 date isa10 interchange time 0345 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs hb s00000000000001 p01234567891234 20171217 16150000 1 x 005010x279a1 element element name value note gs01 functional identifier code hb functional identifier code gs02 application sender’s code s00000000000001 surescripts id gs03 application receiver’s code p01234567891234 provider vendor’s participant id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version the rest of this message is the same as the prior message eligibility response (from pbm/payer to surescripts) eligibility response (from surescripts to provider vendor) full example table full example table element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id s00000000000001 participant id for surescripts isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id p01234567891234 provider vendor’s participant id isa09 interchange date 171217 date isa10 interchange time 0345 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs01 functional identifier code hb functional identifier code gs02 application sender’s code s00000000000001 surescripts id gs03 application receiver’s code p01234567891234 provider vendor’s participant id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version eligibility response (not active) isa 00 01 pwphy12345 zz pbm123456789123 zz s00000000000001 171217 0345 ^ 00501 000000001 0 p \[ element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id pbm123456789123 pbm/payer participant id isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id s00000000000001 surescripts id isa09 interchange date 171217 date isa10 interchange time 0345 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs hb pbm123456789123 s00000000000001 20171217 16150000 1 x 005010x279a1 element element name value note gs01 functional identifier code hb functional identifier code gs02 application sender’s code pbm123456789123 pbm/payer participant id gs03 application receiver’s code s00000000000001 surescripts id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st 271 0001 005010x279a1 element element name value note st01 transaction set identifier code 271 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht 0022 11 3920394930203 20171217 16150000 element element name value note bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 11 indicates purpose of transaction set (value 11 = response) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl 1 20 1 element element name value note hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) nm1 2b 2 pbm company pi pbm123456789123 element element name value note hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name pbm company pbm/payer hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code pbm123456789123 hl 2 1 21 1 element element name value note hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) nm1 1p 1 jonson tim t m d xx 3334444555 element element name value note hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl3\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref eo p01234567891234 element element name value note ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number hl 3 2 22 0 element element name value note hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure nm1 il 1 cross david m mi dd145645645601 element element name value note hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient hl3\ nm108 identification code qualifier mi value mi = member identification number hl3\ nm109 identification code dd145645645601 identification code identifying the patient n3 6785 laughalot lane element element name value note n301 address information 6785 laughalot lane address information n4 trenton nj 08608 element element name value note n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg d8 19720910 m element element name value note dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 date time period dmg03 gender code m gender code (value m = male) ins y 18 element element name value note ins01 yes/no condition or response code y yes/no condition or response code value y = yes ins02 individual relationship code 18 individual relationship code value 18 = sel dtp 291 rd8 20160101 20161231 element element name value note dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier rd8 date time period format qualifier (range of dates expressed in format ccyymmdd ccyymmdd) dtp03 date time period 20160101 20161231 date time period eb 6 30 element element name value note eb01 eligibility or benefit information code 6 value 6 = inactive eb03 coverage level code 30 health plan benefit coverage se 16 0001 element element name value note se01 number of included segments 16 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge 1 1 element element name value note ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea 1 000000001 element element name value note iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number eligibility response (not active) full example table full example table element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id pbm123456789123 pbm/payer participant id isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id s00000000000001 surescripts’ id isa09 interchange date 171217 date isa10 interchange time 0345 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 10 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs01 functional identifier code hb functional identifier code gs02 application sender’s code pbm123456789123 pbm/payer participant id gs03 application receiver’s code s00000000000001 surescripts id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st01 transaction set identifier code 271 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 11 indicates purpose of transaction set (value 11 = response) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name pbm company pbm/payer hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code pbm123456789123 pbm/payer participant id hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl3\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient hl3\ nm108 identification code qualifier mi value mi = member identification number hl3\ nm109 identification code dd145645645601 identification code identifying the patient n301 address information 6785 laughalot lane address information n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 date time period dmg03 gender code m gender code (value m = male) ins01 yes/no condition or response code y yes/no condition or response code value y = yes ins02 individual relationship code 18 individual relationship code value 18 = self dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier rd8 date time period format qualifier (range of dates expressed in format ccyymmdd ccyymmdd) dtp03 date time period 20160101 20161231 date time period eb01 eligibility or benefit information code 6 value 6 = inactive eb03 coverage level code 30 health plan benefit coverage se01 number of included segments 16 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number eligibility response (for specialty and long term care) example isa 00 01 pwphy12345 zz pbm123456789123 zz s00000000000001 171217 0345 ^ 00501 000000001 0 p \[ element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id pbm123456789123 pbm/payer participant id isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id s00000000000001 participant id for surescripts isa09 interchange date 171217 date isa10 interchange time 0345 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs hb pbm123456789123 s00000000000001 20171217 16150000 1 x 005010x279a1 element element name value note gs01 functional identifier code hb functional identifier code gs02 application sender’s code pbm123456789123 pbm/payer participant id gs03 application receiver’s code s00000000000001 surescripts id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st 271 0001 005010x279a1 element element name value note st01 transaction set identifier code 271 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht 0022 11 3920394930203 20171217 16150000 element element name value note bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 11 indicates purpose of transaction set (value 11 = response) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl 1 20 1 element element name value note hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) nm1 2b 2 pbm company pi pbm123456789123 element element name value note hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name pbm company pbm/payer hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code pbm123456789123 pbm/payer participant id hl 2 1 21 1 element element name value note hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) nm1 1p 1 jonson tim t m d xx 3334444555 element element name value note hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl3\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref eo p01234567891234 element element name value note ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number hl 3 2 22 0 element element name value note hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure nm1 il 1 cross david m mi dd145645645601 element element name value note hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient hl3\ nm108 identification code qualifier mi value mi = member identification number hl3\ nm109 identification code dd145645645601 identification code identifying the patient ref 49 01 element element name value note ref01 reference identification qualifier 49 value 49 = family unit number note required when the information source is a pbm/payer and the individual has a suffix to their member id number that is required for use in the ncpdp standard (for person code) ref02 reference identification 01 family unit number (person code) n3 6785 laughalot lane element element name value note n301 address information 6785 laughalot lane address information n4 trenton nj 08608 element element name value note n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg d8 19720910 m element element name value note dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 date time period dmg03 gender code m gender code (value m = male) ins y 18 element element name value note ins01 yes/no condition or response code y yes/no condition or response code value y = yes ins02 individual relationship code 18 individual relationship code value 18 = self dtp 291 rd8 20160101 20161231 element element name value note dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier rd8 date time period format qualifier (range of dates expressed in format ccyymmdd ccyymmdd) dtp03 date time period 20160101 20161231 date time period eb 1 30 plana element element name value note eb01 eligibility or benefit information code 1 value 1 = active eb03 coverage level code 30 health plan benefit coverage eb05 service type code plana health plan name ref 6p dd1 abcgroup element element name value note ref01 reference identification qualifier 6p value 6p = group number ref02 reference identification dd1 group number ref03 description abcgroup group name ref fo 201 element element name value note ref01 reference identification qualifier fo value fo = drug formulary number ref02 reference identification 201 drug formulary number ref cli 201 element element name value note ref01 reference identification qualifier cli value cli = coverage list id ref02 reference identification 201 coverage list id ref n6 234876 av element element name value note ref01 reference identification qualifier n6 value n6 = plan network identification number ref02 reference identification 234876 iin (formerly known as bin) ref03 description av pcn ref ig 201 element element name value note ref01 reference identification qualifier ig value ig = insurance policy number ref02 reference identification 201 copay list id ref als 142345 element element name value note ref01 reference identification qualifier als value als = alternative list id ref02 reference identification 142345 alternative list id eb 1 88 element element name value note eb01 eligibility or benefit information code 1 value 1 = active coverage eb03 coverage level code 88 value 88 = pharmacy eligible for retail pharmacy benefits eb 1 90 element element name value note eb01 eligibility or benefit information code 1 value 1 = active coverage eb03 coverage level code 90 value 90 = mail order prescription drug eligible for mail order pharmacy benefits eb 1 element element name value note eb01 eligibility or benefit information code 1 value 1 = active coverage eligible for benefits specified in msg segment msg specialty pharmacy element element name value note msg01 free form message text specialty pharmacy eligible for specialty pharmacy benefits eb 1 element element name value note eb01 eligibility or benefit information code 1 value 1 = active coverage eligible for benefits specified in msg segment msg ltc element element name value note msg01 free form message text ltc eligible for long term care pharmacy benefits se 29 0001 element element name value note se01 number of included segments 29 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge 1 1 element element name value note ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea 1 000000001 element element name value note iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number eligibility response (for specialty and long term care) full example table full example table element element name value note isa01 authorization information qualifier 00 value 00 = no authorization information present isa02 authorization information (blank) not used filled with blanks isa03 security information qualifier 01 value 01 = password isa04 security information pwphy12345 password needed to correspond with the surescripts system isa05 interchange id qualifier zz qualifier zz = mutually defined isa06 interchange sender id pbm123456789123 pbm/payer participant id isa07 interchange id qualifier zz qualifier zz = mutually defined isa08 interchange receiver id s00000000000001 participant id for surescripts isa09 interchange date 171217 date isa10 interchange time 0345 time isa11 repetition separator ^ repetition separator isa12 interchange control version number 005010 x12 version isa13 interchange control number 000000001 interchange control number unique id isa14 acknowledgment requested 0 no acknowledgment requested isa15 interchange usage indicator p production data isa16 component element separator \[ component element separator gs01 functional identifier code hb functional identifier code gs02 application sender’s code pbm123456789123 pbm/payer participant id gs03 application receiver’s code s00000000000001 surescripts id gs04 date 20171217 date gs05 time 16150000 time gs06 group control number 1 group control number (matches ge02) gs07 responsible agency code x value x = accredited standards committee x12 gs08 version / release / industry identifier code 005010x279a1 x12 version st01 transaction set identifier code 271 identifies the transaction set st02 transaction set control number 0001 unique control number (matches se02) st03 implementation convention reference 005010x279a1 implementation convention reference (matches gs08 and is always populated with 005010x279a1) bht01 hierarchical structure code 0022 value 0022 = information source, information receiver, subscriber, dependent bht02 transaction set purpose code 11 indicates purpose of transaction set (value 11 = response) bht03 reference identification 3920394930203 transaction reference number that ties the request to the response bht04 date 20171217 date bht05 time 16150000 time hl01 hierarchical id number 1 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl03 hierarchical level code 20 value 20 = information source hl04 hierarchical child code 1 code value in loop 2000a hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl1\ nm101 entity identifier code 2b third party administrator hl1\ nm102 entity type qualifier 2 non person entity hl1\ nm103 name last or organization name pbm company pbm/payer hl1\ nm108 identification code qualifier pi value pi = payor identification hl1\ nm109 identification code pbm123456789123 pbm/payer participant id hl01 hierarchical id number 2 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 1 hierarchical parent id number hl03 hierarchical level code 21 value 21 = information receiver hl04 hierarchical child code 1 code value in loop 2000b hl04 is always 1 (additional subordinate hl data segment in this hierarchical structure) hl2\ nm101 entity identifier code 1p value 1p = provider hl2\ nm102 entity type qualifier 1 value 1 = person hl2\ nm103 name last or organization name jonson last name of physician hl2\ nm104 name first tim first name of physician hl3\ nm105 name middle t middle initial of physician hl2\ nm107 name suffix m d name suffix hl2\ nm108 identification code qualifier xx value xx = centers for medicare and medicaid services plan id hl2\ nm109 identification code 3334444555 dr jonson npi number 3334444555 ref01 reference identification qualifier eo value eo = submitter identification number ref02 reference identification p01234567891234 submitter identification number hl01 hierarchical id number 3 sequentially assigned positive number used to identify each specific occurrence of an hl segment within a transaction set hl02 hierarchical parent id number 2 hierarchical parent id number hl03 hierarchical level code 22 value 22 = subscriber hl04 hierarchical child code 0 code value in loop 2000c hl04 is 0 because there is no subordinate hl segment in this hierarchical structure hl3\ nm101 entity identifier code il value il = insured or subscriber hl3\ nm102 entity type qualifier 1 value 1 = person hl3\ nm103 name last or organization name cross last name of patient hl3\ nm104 name first david first name of patient hl3\ nm105 name middle m middle initial of patient hl3\ nm108 identification code qualifier mi value mi = member identification number hl3\ nm109 identification code dd145645645601 identification code identifying the patient ref01 reference identification qualifier 49 value 49 = family unit number note required when the information source is a pbm/payer and the individual has a suffix to their member id number that is required for use in the ncpdp standard (for person code) ref02 reference identification 01 family unit number (person code) n301 address information 6785 laughalot lane address information n401 city name trenton city name n402 state or province code nj state n403 postal code 08608 postal code (zip code) dmg01 date time period format qualifier d8 date time period format qualifier (date expressed in format ccyymmdd) dmg02 date time period 19720910 date time period dmg03 gender code m gender code (value m = male) ins01 yes/no condition or response code y yes/no condition or response code value y = yes ins02 individual relationship code 18 individual relationship code value 18 = self dtp01 date/time qualifier 291 value 291 = plan dtp02 date time period format qualifier rd8 date time period format qualifier (range of dates expressed in format ccyymmdd ccyymmdd) dtp03 date time period 20160101 20161231 date time period eb01 eligibility or benefit information code 1 value 1 = active eb03 coverage level code 30 health plan benefit coverage eb05 service type code plana plan coverage description ref01 reference identification qualifier 6p value 6p = group number ref02 reference identification dd1 group number ref03 description abcgroup group name ref01 reference identification qualifier fo value fo = drug formulary number ref02 reference identification 201 drug formulary number ref01 reference identification qualifier cli value cli = coverage list id ref02 reference identification 201 coverage list id ref01 reference identification qualifier n6 value n6 = plan network identification number ref02 reference identification 234876 iin (formerly known as bin) ref03 description av description for group name ref01 reference identification qualifier ig value ig = insurance policy number ref02 reference identification 201 copay list id ref01 reference identification qualifier als value als = alternative list id ref02 reference identification 142345 alternative list id eb01 eligibility or benefit information code 1 value 1 = active coverage eb03 coverage level code 88 value 88 = pharmacy (retail pharmacy) eb01 eligibility or benefit information code 1 value 1 = active coverage eb03 coverage level code 90 value 90 = mail order prescription drug (mail order pharmacy) eb01 eligibility or benefit information code 1 value 1 = active coverage msg01 free form message text specialty pharmacy eligible for specialty pharmacy benefits eb01 eligibility or benefit information code 1 value 1 = active coverage msg01 free form message text ltc eligible for long term care pharmacy benefits se01 number of included segments 29 number of included segments se02 transaction set control number 0001 transaction set control number (matches st02) ge01 number of transaction sets included 1 number of transaction sets included ge02 group control number 1 group control number (matches gs06) iea01 number of included functional groups 1 number of included functional groups iea02 interchange control number 000000001 interchange control number