Eligibility Request and Response Message Examples

Authorization Information Qualifier

00

Value 00 = No authorization information present

Authorization Information

(blank)

Not used. Filled with blanks.

Security Information Qualifier

01

Value 01 = Password

Security Information

PWPHY12345

Password needed to correspond with the Surescripts system

Interchange ID Qualifier

ZZ

Qualifier ZZ = Mutually Defined

Interchange Sender ID

P01234567891234

Provider vendor’s Participant ID

Interchange ID Qualifier

ZZ

Qualifier ZZ = Mutually Defined

Interchange Receiver ID

S00000000000001

Participant ID for Surescripts

Interchange Date

171217

Date

Interchange Time

0309

Time

Repetition Separator

^

Repetition separator

Interchange Control Version Number

005010

X12 version

Interchange Control Number

000000001

Interchange control number. Unique ID.

Acknowledgment Requested

0

No acknowledgment requested

Interchange Usage Indicator

P

Production data

Component Element Separator

[

Component element separator

Functional Identifier Code

HS

Functional identifier code

Application Sender’s Code

P01234567891234

Participant's ID

Application Receiver’s Code

S00000000000001

Surescripts ID

Date

20171217

Date

Time

16150000

Time

Group Control Number

1

Group control number (matches GE02)

Responsible Agency Code

X

Value X = Accredited Standards Committee X12

Version / Release / Industry Identifier Code

005010X279A1

X12 version

Transaction Set Identifier Code

270

Identifies the transaction set

Transaction Set Control Number

0001

Unique control number (matches SE02)

Implementation Convention Reference

005010X279A1

Implementation convention reference (matches GS08 and is always populated with 005010X279A1)

Hierarchical Structure Code

0022

Value 0022 = Information Source, Information Receiver, Subscriber, Dependent

Transaction Set Purpose Code

13

Indicates purpose of transaction set (value 13 = request)

Reference Identification

3920394930203

Transaction reference number that ties the request to the response

Date

20171217

Date

Time

16150000

Time

Hierarchical ID Number

1

Sequentially assigned positive number used to identify each specific occurrence of an HL segment within a transaction set

Hierarchical Level Code

20

Value 20 = Information Source

Hierarchical Child Code

1

Code value in Loop 2000A HL04 is always 1 (additional subordinate HL data segment in this hierarchical structure)

Entity Identifier Code

2B

Third-Party Administrator

Entity Type Qualifier

2

Non-Person Entity

Name Last or Organization Name

SURESCRIPTS LLC

Source does not know PBM/payer so they put in Surescripts

Identification Code Qualifier

PI

Value PI = Payor Identification

Identification Code

S00000000000001

Surescripts ID

Hierarchical ID Number

2

Sequentially assigned positive number used to identify each specific occurrence of an HL segment within a transaction set

Hierarchical Parent ID Number

1

Hierarchical Parent ID Number

Hierarchical Level Code

21

Value 21 = Information Receiver

Hierarchical Child Code

1

Code value in Loop 2000B HL04 is always 1 (additional subordinate HL data segment in this hierarchical structure)

Entity Identifier Code

1P

Value 1P = Provider

Entity Type Qualifier

1

Value 1 = Person

Name Last or Organization Name

JONSON

Last name of physician

Name First

TIM

First name of physician

Name Middle

T

Middle initial of physician

Name Suffix

M.D.

Name suffix

Identification Code Qualifier

XX

Value XX = Centers for Medicare and Medicaid Services Plan ID

Identification Code

3334444555

Dr. Jonson NPI Number 3334444555

Reference Identification Qualifier

EO

Value EO = Submitter Identification Number

Reference Identification

P01234567891234

Submitter Identification Number

Address Information

55 HIGH STREET

Address information

City Name

SEATTLE

City name

State or Province Code

WA

State

Postal Code

98123

Postal code (zip code)

Hierarchical ID Number

3

Sequentially assigned positive number used to identify each specific occurrence of an HL segment within a transaction set.

Hierarchical Parent ID Number

2

Hierarchical Parent ID Number

Hierarchical Level Code

22

Value 22 = Subscriber

Hierarchical Child Code

0

Code value in Loop 2000C HL04 is 0 because there is no subordinate HL segment in this hierarchical structure

Entity Identifier Code

IL

Value IL = Insured or Subscriber

Entity Type Qualifier

1

Value 1 = Person

Name Last or Organization Name

CROSS

Last name of patient

Name First

DAVID

First name of patient

Name Middle

M

Middle initial of patient

Address Information

6785 LAUGHALOT LANE

Address information

City Name

TRENTON

City name

State or Province Code

NJ

State

Postal Code

08608

Postal code (zip code)

Date Time Period Format Qualifier

D8

Date time period format qualifier (Date Expressed in Format CCYYMMDD)

Date Time Period

19720910

Date Time Period

Gender Code

M

Gender Code (Value M = Male)

Date/Time Qualifier

291

Value 291 = Plan

Date Time Period Format Qualifier

D8

Date time period format qualifier (Date Expressed in Format CCYYMMDD)

Date Time Period

20171217

Date Time Period

Service Type Code

30

Health Plan Benefit Coverage

Number of Included Segments

17

Number of included segments

Transaction Set Control Number

0001

Transaction set control number (matches ST02)

Number of Transaction Sets Included

1

Number of transaction sets included

Group Control Number

1

Group control number (matches GS06)

Number of Included Functional Groups

1

Number of included functional groups

Interchange Control Number

000000001