---
title: Eligibility Request and Response Message Examples
slug: eligibility/guide/eligibility-request-and-response-message-examples
docTags:
createdAt: 2026-06-11T13:19:01.247Z
---
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.
:::hint{type="info"}
**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
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
N3\*55 HIGH STREET\~
| Element | Element Name | Value | Note |
| ------- | ------------------- | -------------- | ------------------- |
| N301 | Address Information | 55 HIGH STREET | Address information |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
N3\*6785 LAUGHALOT LANE\~
| Element | Element Name | Value | Note |
| ------- | ------------------- | ------------------- | ------------------- |
| N301 | Address Information | 6785 LAUGHALOT LANE | Address information |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 | |
:::
:::ExpandableHeading
EQ\*30\~
| Element | Element Name | Value | Note |
| ------- | ----------------- | ----- | ---------------------------- |
| EQ01 | Service Type Code | 30 | Health Plan Benefit Coverage |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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
:::ExpandableHeading
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
:::hint{type="info"}
**Note: **Surescripts has located the patient and populated the PBM Unique Member ID.
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
N3\*55 HIGH STREET\~
| Element | Element Name | Value | Note |
| ------- | ------------------- | -------------- | ------------------- |
| N301 | Address Information | 55 HIGH STREET | Address information |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
N3\*6785 LAUGHALOT LANE\~
| Element | Element Name | Value | Note |
| ------- | ------------------- | ------------------- | ------------------- |
| N301 | Address Information | 6785 LAUGHALOT LANE | Address information |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
EQ\*30\~
| Element | Element Name | Value | Note |
| ------- | ----------------- | ----- | ---------------------------- |
| EQ01 | Service Type Code | 30 | Health Plan Benefit Coverage |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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
:::ExpandableHeading
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
:::ExpandableHeading
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
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
N3\*6785 LAUGHALOT LANE\~
| Element | Element Name | Value | Note |
| ------- | ------------------- | ------------------- | ------------------- |
| N301 | Address Information | 6785 LAUGHALOT LANE | Address information |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
LS\*2120\~
| Element | Element Name | Value | Note |
| ------- | -------------------- | ----- | ----------- |
| LS01 | Loop Identifier Code | 2120 | Loop header |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
LE\*2110\~
| Element | Element Name | Value | Note |
| ------- | -------------------- | ----- | ------------ |
| LE01 | Loop Identifier Code | 2110 | Loop trailer |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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
:::ExpandableHeading
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
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::hint{type="info"}
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
:::ExpandableHeading
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)
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 | |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
N3\*6785 LAUGHALOT LANE\~
| Element | Element Name | Value | Note |
| ------- | ------------------- | ------------------- | ------------------- |
| N301 | Address Information | 6785 LAUGHALOT LANE | Address information |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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
:::ExpandableHeading
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
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
N3\*6785 LAUGHALOT LANE\~
| Element | Element Name | Value | Note |
| ------- | ------------------- | ------------------- | ------------------- |
| N301 | Address Information | 6785 LAUGHALOT LANE | Address information |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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 |
:::
:::ExpandableHeading
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. |
:::
:::ExpandableHeading
MSG\*SPECIALTY PHARMACY\~
| Element | Element Name | Value | Note |
| ------- | ---------------------- | ------------------ | ----------------------------------------- |
| MSG01 | Free-form Message Text | SPECIALTY PHARMACY | Eligible for Specialty Pharmacy Benefits. |
:::
:::ExpandableHeading
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. |
:::
:::ExpandableHeading
MSG\*LTC\~
| Element | Element Name | Value | Note |
| ------- | ---------------------- | ----- | ---------------------------------------------- |
| MSG01 | Free-form Message Text | LTC | Eligible for Long Term Care Pharmacy Benefits. |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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) |
:::
:::ExpandableHeading
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
:::ExpandableHeading
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 |
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