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Section
Title
Change
Reason
2010/12/07
4.13
Differences Between
4010 and 5010
Correction.
2010/12/16
2.2
Connectivity
Correction.
2011/01/09
4.8
Eligibility
Correction.
4.13
Differences Between
4010 and 5010
Clarification.
4.13
Differences Between
4010 and 5010
Clarification.
4.8
Eligibility
Clarification.
Implementation
Overview
Removed VPN
No longer
supported.
2011/01/31
Appendix
A
WebDav Clients
Correction.
2011/02/03
Correction.
2011/03/11
Eligibility
Change to use
number instead
of name for
participant id.
Eligibility
Clarification.
Eligibility
Clarification.
Appendix
A
WebDAV
Correction.
Change to use
number instead
of name for
participant id
2011/01/12
Publication
Date
Section
Title
Change
Reason
ID Load
This was
changed in
error only the
Eligibility and
Formulary &
Benefit sections
were changed
to use new ID.
4.5
Search Options
Correction.
Eligibility
Correction.
Eligibility
Correction.
Eligibility
Correction.
2011/03/18
2011/04/15
Table of Contents
TABLE OF CONTENTS
SECTION 1 Introduction .................................................................................................11
1.1
Document Purpose ....................................................................................11
1.1.1 Other related Surescripts Guides ............................................................11
1.2
Surescripts Overview .................................................................................13
1.3
Surescripts Service Overview ....................................................................13
1.4
Document References ...............................................................................14
SECTION 2 Implementation Overview ............................................................................15
2.1
Implementation, Certification, and Production ............................................15
2.1.1 Implementation Process .........................................................................15
2.1.2 Certification Process ...............................................................................15
2.1.3 Transition to Production ..........................................................................15
2.2
Connectivity ...............................................................................................15
2.2.1 CAQH CORE Phase II Connectivity Rule................................................16
2.2.2 HTTPS POST .........................................................................................16
2.2.2.1
2.2.2.2
2.2.2.3
2.2.2.4
2.2.2.5
2.3
Transaction Timeouts ................................................................................20
2.3.1 Data Load Connectivity ...........................................................................20
2.3.1.1
2.3.1.2
2.3.1.3
2.3.1.4
2.4
2.5
Connect:Direct ................................................................................................ 20
Secure FTP ..................................................................................................... 21
Data Distribution Connectivity ......................................................................... 21
WebDAV ......................................................................................................... 21
Security .....................................................................................................22
Compliance................................................................................................22
3.3.2
3.3.3
3.4
PAGE 5
Table of Contents
3.5
Failure Mode/Response Approach ............................................................ 30
3.5.1 X12 Error Processing.............................................................................. 30
3.6
Connectivity ............................................................................................... 30
SECTION 4 Eligibility ...................................................................................................... 32
4.1
Introduction ............................................................................................... 32
4.2
Relationship to X12N 270/271 Standard .................................................... 32
4.3
Eligibility Message Flow ............................................................................ 33
4.4
Subscriber/Dependent defined .................................................................. 33
4.5
Search Options.......................................................................................... 34
4.5.1 Insufficient information ............................................................................ 34
4.5.2 Multiple Matches..................................................................................... 34
4.6
Patient Match Verification .......................................................................... 34
4.7
Related Transactions................................................................................. 36
4.8
270 Eligibility, Coverage, or Benefit Inquiry ............................................... 36
4.9
271 Eligibility, Coverage, or Benefit Information ........................................ 81
4.10
TA1 Interchange Acknowledgement ........................................................ 182
4.11
999 Implementation Acknowledgement For Health Care Insurance......... 188
4.12
270 and 271 Transaction Examples ........................................................ 208
4.13
Differences Between 4010 and 5010 ....................................................... 217
4.14
Translation .............................................................................................. 219
SECTION 5
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
SECTION 6
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
SECTION 7
7.1
PAGE 6
Table of Contents
7.2
Formulary and Benefit Summary Information Model ................................243
7.3
Formulary and Benefit Data Overview .....................................................244
7.3.1 Formulary Status ..................................................................................244
7.3.2 Payer-Specified Alternatives .................................................................245
7.3.3 Coverage Information ...........................................................................245
7.3.4 Copay Information ................................................................................246
7.3.5 Drug Classification Information .............................................................246
7.3.6 Cross-Reference Information ................................................................247
7.4
11-Digit Representative NDC ...................................................................247
7.5
High-Level Processing Examples ............................................................248
7.5.1 Flow One: Presenting Formulary & Coverage Information ...................248
7.5.2 Flow Two: Presenting Medication Copay .............................................248
7.5.3 Flow Three: Presenting Formulary Alternatives....................................249
7.6
Formulary and Benefit Data Load Roles ..................................................250
7.7
Formulary and Benefit Data Load Process ..............................................250
7.8
Formulary and Benefit Publishing ............................................................252
7.8.1 File Processing Options ........................................................................252
7.8.2 Environment Setup ...............................................................................253
7.8.3 Formulary and Benefit File Naming and Structure.................................253
7.8.3.1
7.8.3.2
PAGE 7
Table of Contents
PAGE 8
Table of Contents
PAGE 9
Table of Contents
PAGE 10
INTRODUCTION
SECTION 1
1.1
Implementation Overview
DOCUMENT PURPOSE
Prescription Benefit Implementation Guide (This Guide)
This Surescripts Prescription Benefit Implementation Guide was created to assist
Pharmacy Benefit Managers (PBMs) and Physician Systems in developing and
transferring messages needed to provide PBM member data (eligibility information,
pharmacy benefit coverage, group-specific formulary information, and medication
history) to physicians in an ambulatory setting.
The audience for this document includes any Participant responsible for developing a
system interface for these electronic prescribing transactions. This guide describes
the Surescripts Prescription Benefit transaction sets and provides other information
needed for their implementation.
1.1.1
PAGE 11
Implementation Overview
The audience for this document includes any Participant responsible for developing
a system interface for these transactions. This guide describes the Surescripts
Prescription History Acute transaction sets and provides other information
needed for their implementation.
Prescription Routing Implementation Guide
This Surescripts Routing Implementation Guide was created to assist Pharmacies
and Prescriber Systems in developing and transferring messages needed to
provide direct conveyance of new prescriptions from physician to pharmacy, and of
refills and change requests from pharmacy to physician.
This document represents XML and EDIFACT implementations. The audience for
this document includes any Participant responsible for developing a system
interface for these electronic prescribing transactions.
Participant Implementation Guide for Eligibility 5010
This Surescripts Eligibility Implementation Guide was created to assist Medicaid
Management Information System (MMIS) vendors that process Medicaid and
Pharmacies in developing and transferring messages needed to provide PBM
member data (eligibility information, pharmacy benefit coverage, group-specific
formulary information, and medication history) to physicians and pharmacies in an
ambulatory setting.
The audience for this document includes any Participant responsible for developing
a system interface for these electronic prescribing transactions. This guide
describes the Surescripts Eligibility transaction sets and provides other information
needed for their implementation.
PAGE 12
1.2
Implementation Overview
SURESCRIPTS OVERVIEW
Surescripts operates the nations largest e-prescription network and supports a
rapidly expanding ecosystem of health care organizations nationwide. Surescripts
was founded on the principles of neutrality, transparency, interoperability, efficiency,
collaboration and quality. Surescripts connects prescribers in all 50 states through
their choice of e-prescribing software to the nations leading payers, chain
pharmacies and independent pharmacies. Available during emergencies or routine
care, the Nations E-Prescription network gives health care providers secure, lowcost, electronic access to prescription and health information that can save their
patients lives, improve efficiency and reduce the cost of health care for all. For more
information, go to www.surescripts.com.
1.3
PAGE 13
Implementation Overview
By eliminating paper, phone and fax, electronic Prescription Routing makes getting
patients the medications they need a safer and more efficient process. Prescription
Routing replaces old, error-prone approaches to sending new prescriptions e.g.
handwritten prescriptions, computer-printed prescriptions and hand or computerfaxed prescriptions with the secure computer-to-computer exchange of
prescriptions between prescribers and pharmacies. Routing new prescriptions
electronically reduces the risk of medication errors associated with poor handwriting,
illegible faxes and manual data entry.
Using Prescription Routing to process prescription renewals saves health care
professionals time and money by dramatically reducing the number of phone calls
and faxes typically associated with the prescription renewal authorization process.
MGMA studies have estimated that the value of the time spent just on prescription
renewal authorization phone calls costs practices $10,000 a year per physician. With
electronic prescription renewals, prescribers can receive electronic authorization
requests directly and securely to practice computers as an alternative to time
consuming phone calls and faxes. Physicians or authorized staff can then return
approvals or denials with a few mouse clicks at their convenience, in seconds, which
could translate into more time with patients for physicians and more efficient use of
staff.
1.4
DOCUMENT REFERENCES
The following documents were referenced in creating this Implementation Guide:
Document Title
ANSI ASC X12 Standards for Implementation
ASC X12N/005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271) Referred to as
the X12 Guide in the rest of this guide.
ASC X12/N/005010X231 Implementation Acknowledgement for Health Care Insurance (999)
NCPDPs Formulary And Benefit Standard Implementation Guide (Version 1, Release 0)
PAGE 14
IMPLEMENTATION OVERVIEW
SECTION 2
2.1
2.1.1
Implementation Overview
2.1.2
CERTIFICATION PROCESS
This phase includes more detailed testing of the transactions and the user interface
to ensure that all Surescripts requirements are met. You will be assigned a
Certification Project Manager who will work with you through the completion of
certification testing. Surescripts will provide more detail surrounding the milestones
that are necessary to certify and move into production. Once a participant passes
certification, services are turned on in production.
2.1.3
TRANSITION TO PRODUCTION
Once Certification is complete, the Participant is ready to move into production.
Surescripts will schedule a hand-off meeting for the business and technical staff of
both Surescripts and the Participant to discuss the following:
2.2
CONNECTIVITY
To transmit transactions between participants, Surescripts supports the HTTPS
method for connectivity. With HTTPS, Participants act as the client and send
transactions to the server on the Surescripts system. With certain transactions,
Surescripts also acts as the client by sending HTTPS requests to servers on
Participants systems.
The preferred connectivity method is HTTPS with the following specifications:
PAGE 15
Implementation Overview
Surescripts uses the standard HTTPS post method to connect and send
transactions to Participants.
The URLs are supplied at the point of integration.
Server certificates with 128-bit encryption are utilized at Surescripts. The
Participant is responsible for providing its own 128-bit (server) digital
certificate.
Separate test and production instances are created for Surescripts and
the Participants systems.
A Participant receiving Point-to-Point messages via SSL from Surescripts
will need to identify the Certificate Authority associated with the
Participants certificate. Surescripts needs to check for the Participants
certificate from that Certificate Authority. If the Participant is using a selfsigned certificate, Surescripts will need the Participants Certificate
Authority certificate.
Outbound HTTP Basic Authentication is an option for Participants, if
needed.
Surescripts supports two methods for inbound connection: CAQH CORE Phase II
Connectivity Rule and HTTP POST. CAQH is a nonprofit alliance of health plans and
trade associations. CAQH launched the Committee on Operating Rules for
Information Exchange (CORE).
2.2.1
2.2.2
HTTPS POST
This section contains supplemental information on the usage of HTTPS
connectivity. The flow of a HTTPS transaction requires the following generic steps:
1. Format the transaction (sending transaction in body)
a. Setting the HTTP content-type to text/xml if xml, or text/plain if not
xml.
b. Write the transaction to the body
2. Send the transaction using the POST method
PAGE 16
Implementation Overview
out = con.getOutputStream();
PAGE 17
Implementation Overview
/**
* Sends a transaction to the Surescripts Network.
* Parameters:
*
*
* Returns the response from the Surescripts Network.
*
PAGE 18
Implementation Overview
Stream newStream=req.GetRequestStream();
newStream.Write(data,0,data.Length);
newStream.Close();
return response;
}
PAGE 19
Implementation Overview
Participants may use one of the following network connectivity methods with
HTTPS.
2.3
Internet:
o Address filtering will be done in the Surescripts firewall.
o Surescripts will work with Participants to review their current
connection speed and bandwidth to ensure they are adequate for
anticipated transaction volumes.
Frame Relay:
o 128 kbps minimum bandwidth over a frame relay circuit between
Surescripts and the Participant.
o The line must be encrypted with 3DES.
o The Participant must allow Surescripts to install and manage two
routers in their data center that connect to their extranet
environment.
o The Participant must have a dual network connection through two
different telecommunication providers.
TRANSACTION TIMEOUTS
Each transaction that Surescripts submits to a Participant has a time-out parameter.
If Surescripts does not get a response from the Participant within the specified time
period, the transaction times out. Surescripts will then respond to the original sender
in the appropriate manner. The Surescripts default time-out period is 10 seconds.
For round-trip transactions, the initiator of a transaction can expect Surescripts to
time out after 30 seconds of attempting to respond to the request. Therefore, the
initiator should set their time-out to a value at least two seconds greater, or 32
seconds.
For a transaction being sent from Surescripts to a Participant, Surescripts utilizes the
Participant specific time-out to determine when the transactions will time out. For
instance, if a Participant has set their Surescripts specific time-out to 10 seconds,
Surescripts will time out after waiting for an acknowledgment for 10 seconds.
Therefore, the recipient should set their time-out to two seconds less than the set 10
seconds.
2.3.1
2.3.1.1 Connect:Direct
Connect:Direct (formerly known as NDM) is supported for the transfer of Master
Patient Index (MPI) data loads, Formulary and Benefit data loads, and ePrescribing
Activity Reports data loads. Surescripts requires TCP/IP protocol and Server-toServer communications. Connect:Direct compression is optional and highly
LAST PUBLISHED 4/15/11
PAGE 20
Implementation Overview
2.3.1.4 WebDAV
WebDAV can be used with the following specifications:
Participants may use one of the following network connectivity methods with
WebDAV:
Internet:
PAGE 21
Implementation Overview
2.4
SECURITY
Each Participant must ensure that appropriate security measures are in place within
its scope of operations to the extent of its interface with Surescripts and Surescripts
systems and data. These security measures must be designed to protect against
fraud and abuse and to maintain patient confidentiality.
Each Participant must provide a Surescripts Trading Partner ID (ISA06 for X12) and
password (ISA04 for X12) in all transactions and a static network path (IP address).
Surescripts will only allow transaction connectivity from the Participant specified
network path. Provision of an otherwise-valid ID and password from a network path
not assigned to the Participant will result in rejection of the transaction, and will be
logged as a potential security violation.
2.5
COMPLIANCE
Prior to using Surescripts for transmissions of electronic prescriptions, each
Participant must verify that such transmissions are legal in the states it services.
Each Participant must also use the Surescripts System in compliance with applicable
restrictions on steering in order that patients retain control over the choice of
pharmacy. A prescriber Participant must not steer a patient to have prescriptions
filled at one pharmacy over another.
Participant pharmacy and prescriber systems must also be protected from fraud and
unauthorized access to the generation of prescriptions and refills. Appropriate
system security should be present to allow only specific authorized persons access
to these activities.
While implementing Prescription Routing according to the NCPDP SCRIPT version
10.6 standard, the participant must comply with the Participant Responsibilities
itemized in the then current Surescripts Network Operations Guide (NOG). These
responsibilities are in the areas of certification requirements, production operations
requirements, directory management, training, and support. Every participant must
have a signed NOG Acknowledgement form on file. The NOG is available to all
network participants and can be obtained as a supplemental file to this document by
sending a request to: support@surescripts.com.
PAGE 22
Implementation Overview
PAGE 23
SECTION 3
3.1
Implementation Overview
TRANSACTIONS OVERVIEW
ID Load
Eligibility Request
Eligibility Request
Eligibility Response
Eligibility Response
Distribution
List
Lookup
PBM
Tech Vendor
Load Response
Patient
Lookup
Surescripts
Figure 3-1 Surescripts Prescription Benefit & Prescription History Transaction Flow
Diagram
PAGE 24
3.2
Implementation Overview
TRANSACTION DESCRIPTIONS
Eligibility Request/Response
The ANSI X12 Health Care Eligibility, Coverage, or Benefit Inquiry (270) and Health
Care Eligibility, Coverage, or Benefit Information (271) transaction sets are used to
request and respond to a patient eligibility check. These transactions enable
prescribers to supply a patients name and demographic information to Surescripts
and get back the following information from each PBM that covers the patient:
Interchange Acknowledgment
This X12 specification, TA1, is utilized to acknowledge receipt/header errors for
batch transactions and errors in real time transactions. For the Surescripts
transaction set, it only applies to the X12 specifications (270 & 271). None of the
other specifications utilize this transaction.
Implementation Acknowledgement
The implementation acknowledgement, or 999, informs the submitter that the
functional group arrived at the destination and is required as a response to receipt of
an X12 transaction in a batch environment, and only errors with real time
transactions. Surescripts only supports a real time environment for the 270/271
transactions so the 999 will only be sent if there are errors. The 999 reports on
errors generated due to data or segment issues that do not comply with the X12
guide.
ID Load/Update (Flat File)/Response
This transaction is used to load a PBMs patient directory into a directory at
Surescripts. This directory is an index Surescripts uses when looking up a patients
prescription benefit. The Patient Directory indicates which PBM(s) can provide
current coverage information. The elements provided are limited to the demographic
data needed for patient searches.
Formulary and Benefit Data Load
As requested or scheduled, the PBM sends group-level formulary updates to
Physician System vendors using the Formulary and Benefit Data Load transaction.
PAGE 25
Implementation Overview
Once the file is retrieved, the Physician System utilizes the file as a local repository
for formulary checks.
Medication History Request/Response
After a patients eligibility has been determined, this transaction is used to retrieve a
listing of dispensed medications that were paid for by a patients PBM. The
transaction format is NCPDP SCRIPT.
3.3
3.3.1
DYNAMIC DELIMITERS
X12 utilize delimiters to separate component, segments, elements, etc. or as
indicators (i.e., for segment repetition.) These delimiters are defined within
specified segments of the transactions. Participants systems need to be able to
dynamically set and handle these delimiters. Surescripts recommends the use of
unprintable characters as delimiters rather than the entire full set of character set
(Refer to Appendix C: Dynamic Delimiters for a full list of acceptable characters).
For X12 transactions, the delimiter set is defined within the ISA segment. The
following is an example:
ISA*00*
*01*PWPOCOUT *ZZ*PCO123
**ZZ*S00000000000001~
In the example above, the asterisk (*) is a delimiter based on its position of
immediately following ISA. The segment delimiter is determined by
calculating the last character of the fixed width row. The row is 106 total
bytes; therefore, the segment delimiter is the 106th character.
PAGE 26
Implementation Overview
3.3.2
DELIMITER EXAMPLES
The delimiters used in the examples below are the ~ for segment separation and
the + for element separation.
Example 1:
NM1*IL*1*SMITH*JOHN*L***34*444115555~
Elements 6 and 7 are not included; therefore, the asterisks (**) act as
placeholders for the omitted elements.
When data elements are omitted from the end of a segment, the data
element delimiters do not need to be used. The segment is ended with a
segment terminator.
Example 2:
Elements 8 and 9 can be omitted in the same segment as Example 1. The
new segment would become:
NM1*IL*1*SMITH*JOHN*L~
And not:
NM1*IL*1*SMITH*JOHN*L****~
Example 3:
Surescripts does not publish segments that are HIPAA compliant but not utilized by
Surescripts. If a transaction contains these segments, it will still be valid and
accepted; but the data within the segment may not be utilized.
ABC*ABC01*ABC02*ABC03*ABC04*ABC05*ABC06~
If elements ABC02 and ABC03 are not used (not shown on the Surescripts EDI
specifications) then no value should be sent. However, the elements must be
represented with a place holder because there are used elements (ABC04, 05 and
06) after them.
This is the correct representation:
ABC*ABC01***ABC04*ABC05*ABC06~
ABC02 and ABC03 must be represented so that it is known that the next data
value is ABC04.
This is the INCORRECT representation:
ABC*ABC01*ABC04*ABC05*ABC06~
If the placeholders for ABC02 and ABC03 are removed, ABC04 would be
mistaken for ABC02.
PAGE 27
Implementation Overview
Example 4:
ABC*ABC01*ABC02*ABC03*ABC04*ABC05*ABC06~
If elements ABC05 and ABC06 are not used (not shown on the Surescripts
EDI specifications) then no value should be sent. When element 05 and 06
are located at the end of the segment there is no need to represent them.
This is the correct representation:
ABC*ABC01*ABC02*ABC03*ABC04~
This is the INCORRECT representation:
ABC*ABC01*ABC02*ABC03*ABC04**~
3.3.3
REPRESENTATION
The following table lists the Field Type Notation used within the transactions:
Type
NCPDP Notation
X12 Notation
Alphanumeric
Date
Decimal
ID Number
Numeric
String
Time
an
DT
R
ID
n
AN
TM
AN
DT
R
ID
Nn
AN
TM
Note: Two periods .. after the Field Type Notation are used to indicate a range. If
no periods are present, the number following the Field Type Notation signifies a
mandatory length. For example,
an..3 means an alphanumeric with range from zero to three characters.
an3 means an alphanumeric with three characters required.
only when there are significant digits to the right of the decimal
when there is a digit before and after the decimal point
not with whole numbers
For example, consider the following possible values for a 5-digit field:
Correct:
2.515
251.5
25.15
Incorrect:
.2515
2515.
3.00
2515
0.2515
2.5
Alpha characters are the subset of upper case letters (A-Z). Lower case
letters are not recommended.
Numeric characters are the subset of numbers (0-9).
Printable characters include, but are not limited to # ! $ % & _ -.
PAGE 28
Implementation Overview
X12
Description
Segments that are not used have been removed from the transaction
specifications.
Element Attributes:
NCPDP
X12
Description
Elements that are not used have been grayed out (for NCPDP transactions) or
removed (for X12 transactions) from the specifications.
3.4
TRANSACTION VALIDATION
Surescripts will certify that participants are in compliance with the transaction
specifications outlined in this Guide during implementation and will continue to
validate once in production.
To validate a transaction, Surescripts:
PAGE 29
3.5
Implementation Overview
3.5.1
3.6
CONNECTIVITY
Surescripts has established standard connectivity methods for integration with
participants. Surescripts technical staff will work with the Participant during
implementation to determine the best connectivity method for their environment. The
implemented connectivity method depends on the Participants existing infrastructure
and the anticipated transaction volumes between the Participant and Surescripts.
PAGE 30
Implementation Overview
PAGE 31
SECTION 4
4.1
Eligibility
ELIGIBILITY
INTRODUCTION
This section provides guidelines for the data messaging interfaces between the
Physician System and Pharmacy Benefit Managers (PBMs). Standard segments will
be required for commonly transmitted data such as basic patient demographics and
eligibility information.
The Patient and Eligibility Data will be transmitted between the Physician System,
Surescripts, and PBMs using the currently accepted ANSI ASC X12 envelope
segments. Message formats used include the X12N 270 (Eligibility Benefit Inquiry)
and the X12N 271 (Eligibility Benefit Response).
The requester is a Physician System, and the eligibility responder is a PBM.
4.2
PAGE 32
Eligibility
If a PBM Participant submits an eligibility response that does not comply with the
X12N 270/271 transaction standard, Surescripts will return a 999 response. If a PBM
Participant submits an eligibility response that complies with the X12N 270/271
transaction but contains information that is unexpected by Surescripts, Surescripts
will pass the response to the requesting Physician System Participant. However,
PBM participants should be aware that such responses may not be understood or
usable by the recipient Physician System Participant.
4.3
4.4
SUBSCRIBER/DEPENDENT DEFINED
The X12 Eligibility transaction is structured so that the requester can send in both a
subscriber and a dependant. From the requester point of view, the desire is to find
out eligibility for a patient, regardless if they are the subscriber or dependent. Since
the transaction differentiates between a subscriber and dependent, the following flow
is assumed if the requester sends in the patient only, and the patient is a dependent.
1. The requester sends a patient in the 270 within the subscriber loop.
2. The patient is found by Surescripts and sent to the PBM.
3. The PBM determines that the patient is a dependent and cannot be uniquely
defined. (They need to have the subscriber information along with the dependent
information to make them unique).
4. The PBM responds with the patient information in the dependent loop with:
a. Corresponding INS info in the dependent loop relaying the person code.
b. The Subscriber loop blank except for the placeholder (HL and NM12
segment).
Note: If possible, the PBM can populate the subscriber information in the
subscriber loop.
Also, if the patient is submitted in the dependent loop and its determined they are
subscriber they must be moved to subscriber loop.
When moving the patient, the TRN loops must also be moved. See section 1.4.2 of
the 005010X279 guide for more details.
PAGE 33
4.5
Eligibility
SEARCH OPTIONS
Unlike many other X12 transactions, the 270 transaction has the built-in flexibility of
allowing a user to enter whatever patient information they have on hand to identify
them to an information source. There are five key fields that are recommended to
improve the chance of a match. They are first name, last name, date of birth, gender
and zip code.
By design, the 270 allows the requester to submit a patient as a subscriber or a
dependent with a subscriber. Surescripts will follow the following process to
determine the unique ID for the patient to retrieve eligibility.
4.5.1
INSUFFICIENT INFORMATION
In the event that insufficient identifying elements are sent to Surescripts to uniquely
identify a patient, Surescripts returns a 271 with an AAA segment identifying
Subscriber/Insured Not Found or Patient Not Found and sends
recommendations for future searches, if appropriate.
4.5.2
MULTIPLE MATCHES
In the event that multiple matches are found, Surescripts returns a 271 with an AAA
segment identifying Subscriber/Insured Not Found or Patient Not Found and, if
possible, lists the missing data elements needed to help identify an exact patient
match.
4.6
PAGE 34
Eligibility
State N4(2) *
Zip N4(3)
DOB DMG(2)
Gender DMG(3)
PAGE 35
Eligibility
This is an example where the patient is not found, so none of the patient
information is returned.
Request sends in: Joe M Doe, DOB 19550412, Gender Male, and Address 55111
Responder returns: No Patient Data and an AAA segment with error 67 patient
not found.
4.7
RELATED TRANSACTIONS
Based on error processing, Surescripts is utilizing the following transactions to inform
the requester of particular system issues.
Interchange Acknowledgment: The TA1 is utilized to inform the requester
of errors when the errors occur at the header ISA/IEA level.
Implementation Acknowledgement: The 999 informs the requester of
errors for segments included in the GS/GE loop.
4.8
HS
Introduction:
This Surescripts draft specification contains the format and establishes the data contents of
the Eligibility, Coverage or Benefit Inquiry Transaction Set (270) for use within the context of
an ePrescribing environment. For the complete set of segments, refer to the X12 guide.
Since Surescripts uniquely identifies each patient, the subscriber level should be
used instead of the dependant level regardless of whether the patient is a subscriber
or dependent. However, receivers of the 270 should be able to handle patients at the
dependent level since the standard allows it.
Heading:
Page #
Seg ID
Name
Req
Des
Max
Use
ISA
GS
ST
BHT
R
R
R
R
1
1
1
1
Loop
Repeat
Header
38
41
43
44
Detail
46
HL
48
NM1
49
HL
LOOP ID 2000A
Information Source Level(PBM)
LOOP ID 2100A
Information Source Name
LOOP ID 2000B
Information Receiver Level(Physician)
LOOP ID 2100B
1
1
1
PAGE 36
50
52
NM1
REF
53
54
N3
N4
55
56
HL
TRN
58
60
61
62
63
64
NM1
REF
N3
N4
DMG
DTP
65
EQ
66
67
HL
TRN
69
71
72
73
74
75
NM1
REF
N3
N4
DMG
DTP
76
EQ
SE
GE
IEA
Eligibility
R
S
1
9
S
S
1
1
S
S
1
2
R
S
S
S
S
S
1
9
1
1
1
2
S
S
1
2
R
S
S
S
S
S
1
9
1
1
1
1
R
R
R
1
1
1
Trailer
78
79
80
PAGE 37
270 Segment:
Eligibility
Loop:
Level:
Usage:
Heading
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Ref.
Data
Des.
Element
ISA01
I01
Name
Attributes
ID 2/2
ISA02
I02
Authorization Information
AN 10/10
ISA03
I03
ID 2/2
ISA04
I04
Password
Security Information
AN 10/10
This is used for identifying the security information about the interchange
sender or the data in the interchange; the type of information is set by the
Security Information Qualifier (I03)
*From the POC/PPMS, this is the Password assigned by Surescripts for the
POC/PPMS.
*From Surescripts, this is the password for Surescripts to get to the
PBM/Payer.
M
ISA05
I05
Interchange ID Qualifier
ID 2/2
ISA06
I06
Mutually Defined
Interchange Sender ID
AN 15/15
Identification code published by the sender for other parties to use as the
receiver ID to route data to them; the sender always codes this value in the
sender ID element
PAGE 38
Eligibility
ISA07
I05
Interchange ID Qualifier
ID 2/2
ISA08
I07
Mutually Defined
Interchange Receiver ID
AN 15/15
ISA09
I08
Interchange Date
DT 6/6
TM 4/4
ISA10
I09
Interchange Time
Time of the interchange
*Time format HHMM required.
ISA11
I65
Repetition Separator
M
1/1
Type is not applicable; the repetition separator is a delimiter and not a data
element; this field provides the delimiter used to separate repeated occurrences of
a simple data element or a composite data structure; this value must be different
than the data element separator, component element separator, and the segment
terminator.
*Surescripts recommends using Hex 1F.
ISA12
I11
ID 5/5
ISA13
I12
N0 9/9
ISA14
I13
Acknowledgment Requested
ID 1/1
PAGE 39
Eligibility
*Since these transactions are real time only, Surescripts does not use this
field to determine whether to create a TA1 acknowledgement.
ISA15
I14
Usage Indicator
ID 1/1
ISA16
I15
Production Data
Test Data
AN 1/1
PAGE 40
270 Segment:
Eligibility
Loop:
Level:
Usage:
Heading
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
The data interchange control number GS06 in this header must be identical to
the same data element in the associated functional group trailer, GE02.
A functional group of related transaction sets, within the scope of X12 standards,
consists of a collection of similar transaction sets enclosed by a functional group
header and a functional group trailer.
Ref.
Data
Des.
Element
GS01
479
Name
Attributes
ID 2/2
GS02
142
AN 2/15
GS03
124
AN 2/15
GS04
373
Date
DT 8/8
TM 4/8
GS05
337
Time
GS06
28
N0 1/9
PAGE 41
Eligibility
*The control number should be unique across all groups within this
transaction set. This ID will be returned on an AK102 of the 999
acknowledgement if an error occurs. Providing unique numbers will assist in
resolving errors and tracking messages.
M
GS07
455
ID 1/2
Code used in conjunction with Data Element 480 to identify the issuer of the
standard
X
GS08
480
AN 1/12
Code indicating the version, release, subrelease, and industry identifier of the
EDI standard being used, including the GS and GE segments; if code in DE455
in GS segment is X, then in DE 480 positions 1-3 are the version number;
positions 4-6 are the release and subrelease, level of the version; and positions
7-12 are the industry or trade association identifiers (optionally assigned by
user); if code in DE455 in GS segment is T, then other formats are allowed
005010X279
Draft Standards Approved for Publication by ASC X12
Procedures Review Board through October 2003, as
published in this implementation guide.
PAGE 42
270 Segment:
Eligibility
Loop:
Level:
Usage:
Heading
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
The transaction set identifier (ST01) is used by the translation routines of the
interchange partners to select the appropriate transaction set definition (e.g., 810
selects the Invoice Transaction Set).
Comments:
Notes:
Use this control segment to mark the start of a transaction set. One ST segment
exists for every transaction set that occurs within a functional group.
Example: ST*270*0001*005010X279~
Data Element Summary
Ref.
Data
Des.
Element
ST01
143
Name
Attributes
ID 3/3
ST02
329
AN 4/9
Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
The transaction set control numbers in ST02 and SE02 must be identical.
This unique number also aids in error resolution research. Start with the
number, for example "0001", and increment from there. This number must
be unique within a specific group and interchange, but can repeat in other
groups and interchanges.
*This ID will be returned on an AK202 of the 999 acknowledgement if an
error occurs. Providing a unique number will assist in resolving errors and
tracking messages.
M
ST03
1705
AN 1/35
PAGE 43
270 Segment:
Eligibility
Loop:
Level:
Usage:
Heading
Mandatory
Max Use:
Purpose:
To define the business hierarchical structure of the transaction set and identify the
business application purpose and reference data, i.e., number, date, and time
Syntax Notes:
Semantic Notes:
BHT03 is the number assigned by the originator to identify the transaction within
the originator's business application system.
BHT04 is the date the transaction was created within the business application
system.
BHT05 is the time the transaction was created within the business application
system.
Comments:
Notes:
Use this required segment to start the transaction set and indicate the sequence of the
hierarchical levels of information that will follow in Table 2.
Example: BHT*0022*13*199800114000001*19980101*1400~
Ref.
Data
Des.
Element
BHT01
1005
Name
Attributes
ID 4/4
BHT02
353
ID 2/2
Request
Note: Surescripts Participants utilize this option only;
(Cancellation) and 36 (Authority to Deduct) are not
utilized.
BHT03
127
Reference Identification
AN 1/50
PAGE 44
Eligibility
point, such as when the transaction is passed from one clearinghouse to another
clearinghouse. This identifier is to be returned in the corresponding 271
transaction's BHT03. This identifier will only be returned by the last entity to
handle the 270. This identifier will not be passed through the complete life of the
transaction. All recipients of 270 transactions are required to return the Submitter
Transaction Identifier in their 271 response if one is submitted.
Submitter Transaction Identifier
M
BHT04
373
Date
DT 8/8
TM 4/8
BHT05
337
Time
PAGE 45
270 Segment:
Loop:
2000A
Level:
Detail
Usage:
Eligibility
Mandatory
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HL01 shall contain a unique alphanumeric number for each occurrence of the HL
segment in the transaction set. For example, HL01 could be used to indicate the
number of occurrences of the HL segment, in which case the value of HL01
would be "1" for the initial HL segment and would be incremented by one in each
subsequent HL segment within the transaction.
HL03 indicates the context of the series of segments following the current HL
segment up to the next occurrence of an HL segment in the transaction. For
example, HL03 is used to indicate that subsequent segments in the HL loop form
a logical grouping of data referring to shipment, order, or item-level information.
HL04 indicates whether or not there are subordinate (or child) HL segments
related to the current HL segment.
Segment to identify the hierarchical or entity level of information being conveyed. The HL
structure allows for the efficient nesting of related occurrences of information. The
developers' intent is to clearly identify the relationship of the patient to the subscriber and
the subscriber to the provider. Additionally, multiple subscribers and/or dependents (i.e.,
the patient) can be grouped together under the same provider or the information for
multiple providers or information receivers can be grouped together for the same payer or
information source.
In a batch environment, only one Loop 2000A (Information Source) loop is to be created
for each unique information source in a transaction. Each Loop 2000B (Information
Receiver) loop that is subordinate to an information source is to be contained within only
one Loop 2000A loop. There has been a misuse of the HL structure creating multiple
Loops 2000As for the same information source. This is not the developer's intended use of
the HL structure, and defeats the efficiencies that are designed into the HL structure.
An example of the overall structure of the transaction set when used in batch mode is:
Information Source (Loop 2000A)
Information Receiver (Loop 2000B) Physician
Subscriber (Loop 2000C)
Dependent (Loop 2000D)
Eligibility or Benefit Inquiry
Example: HL*1**20*1~
LAST PUBLISHED 4/15/11
PAGE 46
Eligibility
Ref.
Data
Des.
Element
HL01
628
Name
Attributes
Hierarchical ID Number
AN 1/12
HL03
735
ID 1/2
Information Source
Identifies the payer, maintainer, or source of the
information
HL04
736
ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
Use this code to indicate whether there are additional hierarchical levels
subordinate to the current hierarchical level.
Because of the hierarchical structure, and because an additional HL always
exists in this transaction, the code value in the HL04 at the Loop 2000A level
should always be "1".
1
PAGE 47
270 Segment:
Loop:
2100A
Level:
Detail
Usage:
Eligibility
Mandatory
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this NM1 loop to identify an entity by name and/or identification number. This NM1
loop is used to identify the eligibility or benefit information source, (e.g., insurance
company, HMO, IPA, employer).
Example: NM1*2B*2*SURESCRIPTS LLC*****PI*SURESCRIPTS~
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
ID 1/1
NM103
1035
Person
AN 1/60
NM108
66
ID 1/2
NM109
67
Identification Code
AN 2/80
PAGE 48
270 Segment:
Loop:
2000B
Level:
Detail
Usage:
Eligibility
Mandatory
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
HL01
628
Name
Attributes
Hierarchical ID Number
AN 1/12
HL02
734
AN 1/12
Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
M
HL03
735
ID 1/2
Information Receiver
Identifies the provider or party(ies) who are the recipient(s)
of the information
HL04
736
ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
1
PAGE 49
270 Segment:
Loop:
2100B
Level:
Detail
Usage:
Eligibility
Mandatory
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name and/or identification number. This NM1
loop is used to identify the eligibility/benefit information receiver (e.g., provider, medical
group, employer, IPA, or hospital).
Example: NM1*1P*1*JONES*TIM****XX*111223333~
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
ID 1/1
NM103
1035
Non-Person Entity
AN 1/60
NM104
1036
Name First
AN 1/35
AN 1/25
AN 1/10
NM105
1037
Name Middle
Individual middle name or initial
Use this name only if NM102 is "1".
NM107
1039
Name Suffix
Suffix to individual name
PAGE 50
Eligibility
Use this for the suffix to an individual's name; e.g., Sr., Jr. or III.
Use this only if NM102 is "1".
M
NM108
66
ID 1/2
NM109
67
Identification Code
AN 2/80
PAGE 51
270 Segment:
Loop:
2100B
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Comments:
Notes:
Use this segment when needed to convey other or additional identification numbers for the
information receiver. The type of reference number is determined by the qualifier in
REF01.
*Surescripts defined participant ID for the POC/PPMS Vendor.
Example: REF*EO*477563928~
Ref.
Data
Des.
Element
REF01
128
Name
Attributes
ID 2/3
REF02
127
Reference Identification
AN 1/50
REF03
352
Description
AN 1/80
A free-form description to clarify the related data elements and their content
*Not Used for the EO qualifier.
PAGE 52
270 Segment:
Loop:
2100B
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment if the information receiver is a provider who has multiple locations and it
is needed to identify the location relative to the request.
Example: N3*201 PARK AVENUE*SUITE 300~
Ref.
Data
Des.
Element
N301
166
Name
Attributes
Address Information
AN 1/55
AN 1/55
Address information
Use this information for the first line of the address information.
O
N302
166
Address Information
Address information
Use this information for the second line of the address information.
Required if a second address line exists.
PAGE 53
270 Segment:
Loop:
2100B
Level:
Detail
Usage:
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Eligibility
A combination of either N401 through N404, or N405 and N406 may be adequate
to specify a location.
Semantic Notes:
Comments:
Notes:
Use this segment if the information receiver is a provider who has multiple locations and it
is needed to identify the location relative to the request.
Example: N4*NEW YORK*NY*10003~
Ref.
Data
Des.
Element
N401
19
Name
City Name
Attributes
O
AN 2/30
N402
156
ID 2/2
N403
116
Postal Code
ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)
Required when the address is in the United States of America, including its
territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
O
N404
26
Country Code
ID 2/3
PAGE 54
270 Segment:
HL Subscriber Level
Loop:
2000C
Level:
Detail
Usage:
Eligibility
Mandatory
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
HL01
628
Name
Attributes
Hierarchical ID Number
AN 1/12
HL02
734
AN 1/12
Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
M
HL03
735
ID 1/2
Subscriber
Identifies the employee or group member who is covered
for insurance and to whom, or on behalf of whom, the
insurer agrees to pay benefits
HL04
736
ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
PAGE 55
270 Segment:
Loop:
2000C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Trace numbers assigned at the subscriber level are intended to allow tracing of an
eligibility/benefit transaction when the subscriber is the patient.
The information receiver may assign one TRN segment in this loop if the subscriber is the
patient. A clearinghouse may assign one TRN segment in this loop if the subscriber is the
patient. See Section 1.4.6 Information Linkage of the X12 HIPAA Implementation Guide.
Example: TRN*1*98175-012547*9877281234*RADIOLOGY~
Ref.
Data
Des.
Element
TRN01
481
Name
Attributes
ID 1/2
AN 1/50
TRN02
127
Reference Identification
TRN03
509
AN 10/10
TRN04
127
Reference Identification
AN 1/50
PAGE 56
Eligibility
PAGE 57
270 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name and/or identification number. Use this NM1
loop to identify the insured or subscriber.
Example: NM1*IL*1*SMITH*ROBERT*B***MI*33399999~
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
Insured or Subscriber
ID 1/1
NM103
1035
Person
AN 1/60
NM104
1036
Name First
AN 1/35
NM105
1037
Name Middle
AN 1/25
NM107
1039
Name Suffix
SURESCRIPTS CONFIDENTIAL AND PROPRIETARY,
NOT TO BE COPIED OR DISTRIBUTED
AN 1/10
PAGE 58
Eligibility
NM108
66
ID 1/2
NM109
67
Identification Code
AN 2/80
PAGE 59
270 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Notes:
Ref.
Data
Des.
Element
REF01
128
Name
Attributes
ID 2/3
EJ
M
REF02
127
Reference Identification
AN 1/50
PAGE 60
270 Segment:
N3 Subscriber Address
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment when needed to convey the address information for the subscriber. Use
if information is known and will assist in identification of the person named, particularly
when not utilizing the HIPAA search option.
Required if the subscriber is a patient.
Example: N3*15197 BROADWAY AVENUE*APT 215~
Ref.
Data
Des.
Element
N301
166
Name
Address Information
Attributes
M
AN 1/55
Address information
Use this information for the first line of the address information..
O
N302
166
Address Information
AN 1/55
Address information
Use this information for the second line of the address information.
Required if a second address line exists.
PAGE 61
270 Segment:
Loop:
2100C
Level:
Detail
Usage:
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Eligibility
A combination of either N401 through N404, or N405 and N406 may be adequate
to specify a location.
Semantic Notes:
Comments:
Notes:
Use this segment when needed to convey the city, state, and ZIP code for the subscriber.
Use if information is known and will assist in identification of the person named,
particularly when not utilizing the HIPAA search option.
Example: N4*NEW YORK*NY*10003~
Ref.
Data
Des.
Element
N401
19
Name
City Name
Attributes
O
AN 2/30
ID 2/2
N402
156
N403
116
Postal Code
ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)
Required when the address is in the United States of America, including its
territories, or Canada, or when a postal code exists for the country in N404. If
not required by this implementation guide, do not send.
O
N404
26
Country Code
ID 2/3
PAGE 62
270 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
DMG01
1250
Name
Attributes
ID 2/3
Code indicating the date format, time format, or date and time format
Use this code to indicate the format of the date of birth that follows in DMG02.
See X12 Guide.
D8
O
DMG02
1251
AN 1/35
DMG03
1068
Gender Code
ID 1/1
Female
Male
PAGE 63
270 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
DTP02 is the date or time or period format that will appear in DTP03.
Comments:
Notes:
Ref.
Data
Des.
Element
DTP01
374
Name
Attributes
Date/Time Qualifier
ID 3/3
Plan
Begin and end dates of the service being rendered
DTP02
1250
ID 2/3
Code indicating the date format, time format, or date and time format
D8
RD8
M
DTP03
1251
AN 1/35
PAGE 64
270 Segment:
Loop:
2110C
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
EQ01
1365
Name
Attributes
ID 1/2
* Instead of specifying a specific service type code, this code allows the
information source to respond with all the relevant service types. If other service
types are sent, the responder will only respond to pharmacy-related coverages.
PAGE 65
270 Segment:
Eligibility
HL Dependent Level
Loop:
2000D
Optional
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
HL01
628
Name
Attributes
Hierarchical ID Number
AN 1/12
HL02
734
AN 1/12
Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
M
HL03
735
ID 1/2
Dependent
Identifies the individual who is affiliated with the
subscriber, such as spouse, child, etc., and therefore may
be entitled to benefits
HL04
736
ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
0
PAGE 66
270 Segment:
Eligibility
Loop:
2000D
Optional
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Trace numbers assigned at the dependent level are intended to allow tracing of an
eligibility/benefit transaction when the dependent is the patient.
See the X12 HIPAA Implementation Guide (Section 1.4.6 Information Linkage).
Example: TRN*1*98175-012547*9877281234*RADIOLOGY~
TRN*1*109834652831*9XYZCLEARH*REALTIME~
Ref.
Data
Des.
Element
TRN01
481
Name
Attributes
ID 1/2
AN 1/50
TRN02
127
Reference Identification
TRN03
509
AN 10/10
TRN04
127
Reference Identification
AN 1/50
PAGE 67
Eligibility
PAGE 68
270 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name. This NM1 loop is used to identify the
dependent of an insured or subscriber.
See X12 Guide.
Example: NM1*03*SMITH*MARY LOU*R~
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
Dependent
ID 1/1
NM103
1035
Person
AN 1/60
NM104
1036
Name First
AN 1/35
NM105
1037
Name Middle
AN 1/25
NM107
1039
Name Suffix
AN 1/10
PAGE 69
Eligibility
PAGE 70
270 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Comments:
Notes:
Use this segment when needed to convey identification numbers for the dependent. The
type of reference number is determined by the qualifier in REF01.
See X12 Guide.
Example: REF*1L*660415~
Ref.
Data
Des.
Element
REF01
128
Name
Attributes
ID 2/3
EJ
M
REF02
127
Reference Identification
AN 1/50
PAGE 71
270 Segment:
Eligibility
N3 Dependent Address
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment when needed to convey the address information for the dependent. Use
if information is known and will assist in identification of the person named, particularly
when not utilizing the HIPAA search option.
Example: N3*15197 BROADWAY AVENUE*APT 215~
Ref.
Data
Des.
Element
N301
166
Name
Attributes
Address Information
AN 1/55
AN 1/55
Address information
Use this information for the first line of the address information.
O
N302
166
Address Information
Address information
Use this information for the second line of the address information.
Required if a second address line exists.
PAGE 72
270 Segment:
Loop:
2100D
Level:
Summary
Usage:
Optional
Mandatory
Max Use:
Purpose:
Syntax Notes:
Eligibility
A combination of either N401 through N404, or N405 and N406 may be adequate
to specify a location.
Semantic Notes:
Comments:
Notes:
Use this segment when needed to convey the city, state, and ZIP code for the dependent.
Use if information is known and will assist in identification of the person named,
particularly when not utilizing the HIPAA search option.
Example: N4*NEW YORK*NY*10003~
Ref.
Data
Des.
Element
N401
19
Name
City Name
Attributes
O
AN 2/30
ID 2/2
N402
156
N403
116
Postal Code
ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)
Required when the address is in the United States of America, including its
territories, or Canada, or when a postal code exists for the country in N404. If
not required by this implementation guide, do not send.
O
N404
26
Country Code
ID 2/3
PAGE 73
270 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment when needed to convey the birth date or gender demographic
information for the dependent.
See X12 Guide.
Example: DMG*D8*19430121*F~
Ref.
Data
Des.
Element
DMG01
1250
Name
Attributes
ID 2/3
Code indicating the date format, time format, or date and time format
Use this code to indicate the format of the date of birth that follows in DMG02.
See X12 Guide.
D8
O
DMG02
1251
AN 1/35
DMG03
1068
Gender Code
ID 1/1
Female
Male
PAGE 74
270 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
DTP02 is the date or time or period format that will appear in DTP03.
Comments:
See X12 Guide.
Absence of a Plan date indicates the request is for the date the transaction is processed
and the information source is to process the transaction in the same manner as if the
processing date was sent.
Example: DTP*291*D8*19950818~
Ref.
Data
Des.
Element
DTP01
374
Name
Attributes
Date/Time Qualifier
ID 3/3
Plan
Begin and end dates of the service being rendered
DTP02
1250
ID 2/3
Code indicating the date format, time format, or date and time format
D8
RD8
M
DTP03
1251
AN 1/35
PAGE 75
270 Segment:
Loop:
2110D
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
EQ01
1365
Name
Attributes
ID 1/2
PAGE 76
270 Segment:
EQ
Loop:
2110D2
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
EQ01
1365
Name
Attributes
ID 1/2
PAGE 77
270 Segment:
Eligibility
Loop:
Level:
Summary
Usage:
Mandatory
Max Use:
Purpose:
To indicate the end of the transaction set and provide the count of the transmitted
segments (including the beginning (ST) and ending (SE) segments)
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to mark the end of a transaction set and provide control information on
the total number of segments included in the transaction set.
Example: SE*41*0001~
Ref.
Data
Des.
Element
SE01
96
Name
Number of Included Segments
Attributes
M
N0 1/10
SE02
329
AN 4/9
Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
The transaction set control numbers in ST02 and SE02 must be identical. This
unique number also aids in error resolution research. Start with a number, for
example 0001, and increment from there. This number must be unique within
a specific functional group (segments GS through GE) and interchange, but can
repeat in other groups and interchanges.
PAGE 78
270 Segment:
Eligibility
Loop:
Level:
Summary
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
The data interchange control number GE02 in this trailer must be identical to the
same data element in the associated functional group header, GS06.
Comments:
Ref.
Data
Des.
Element
GE01
97
Name
Number of Transaction Sets Included
Attributes
M
N0 1/6
GE02
28
N0 1/9
PAGE 79
270 Segment:
Eligibility
Loop:
Level:
Summary
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes :
Semantic Notes :
Comments :
Ref.
Data
Des.
Element
IEA01
I16
Name
Number of Included Functional Groups
Attributes
M
N0 1/5
IEA02
I12
N0 9/9
PAGE 80
4.9
Eligibility
HB
This Surescripts draft specification contains the format and establishes the data contents of
the Eligibility, Coverage or Benefit Information Transaction Set (271) for use within the
context of an ePrescribing environment. For the complete set of segments, refer to the X12
guide.
The X12 guide defines loops 2110C/D and 2120C/D. This guide has numbered occurrences
of these loops as C1 through C4 to help clarify what should go in each occurrence of the
loop.
Since Surescripts uniquely identifies each patient, the subscriber level should be
used instead of the dependant level regardless of whether the patient is a subscriber
or dependent. However, receivers of the 270 should be able to handle patients at the
dependent level since the standard allows it.
Heading:
Page #
Seg ID
Name
Req
Des
Max Loop
Use Repeat
R
R
R
R
1
1
1
1
Header
84
87
89
91
ISA
GS
ST
BHT
Detail
93
94
HL
AAA
96
97
NM1
AAA
99
HL
100
102
NM1
REF
103
AAA
105
106
HL
TRN
108
110
NM1
REF
111
112
113
116
N3
N4
AAA
DMG
R
S
1
9
1
R
S
1
9
R
S
1
1
S
S
1
3
1
1
1
R
S
1
9
S
S
S
S
1
1
9
1
PAGE 81
117
119
INS
DTP
120
122
EB
REF
124
123
127
128
DTP
AAA
MSG
LS
129
131
NM1
LE
132
134
135
137
138
EB
DTP
AAA
MSG
LS
139
141
NM1
LE
142
144
HL
TRN
146
NM1
148
REF
149
150
151
153
154
156
N3
N4
AAA
DMG
INS
DTP
157
EB
159
REF
161
Subscriber Relationship
Subscriber Date
LOOP ID 2110C1
Subscriber Eligibility or Benefit Information
Subscriber Additional Identification (Plan ID, Group ID/Name,
Formulary ID, Alternative ID, Coverage List ID, BIN/PCN, and Copay
ID)
Subscriber Eligibility/Benefit Date
Subscriber Request Validation
Message Text
Loop Header2110C1
LOOP ID 2120C1
Subscriber Benefit Related Entity Name 2120C1
Loop Trailer 2110C1
LOOP ID 2110C2-5 (One loop for retail, one for mail order, and
optionally, one for specialty pharmacy, and/ or LTC)
Subscriber Eligibility or Benefit Information
Subscriber Eligibility/Benefit Date
Subscriber Request Validation
Message Text
Loop Header 2110C2-5
LOOP ID 2120C2-5
Subscriber Benefit Related Entity Name 2120C2-5
Loop Trailer 2110C2-5
LOOP ID 2000D
Dependent Level
Dependent Trace Number
LOOP ID 2100D
Dependent Name
Eligibility
S
S
1
9
1
S
S
1
9
S
S
S
S
20
9
10
1
S
S
1
1
>0
S
S
S
S
S
1
20
9
10
1
S
S
1
1
S
S
1
3
S
S
S
S
S
S
1
1
9
1
1
9
1
9
DTP
20
162
AAA
164
MSG
Message Text
10
165
LS
166
168
NM1
LE
Loop Header2110D1
LOOP ID 2120D1
Dependent Benefit Related Entity Name 2120D1
Loop Trailer 2110D1
LOOP ID 2110D2-5 (One loop for 88-retail, one for 90- mail order, and
optionally one for specialty pharmacy, and/or LTC)
Dependent Eligibility or Benefit Information
S
S
1
1
169
EB
23
1
23
1
1
23
>1
S
PAGE 82
Eligibility
171
DTP
20
172
174
AAA
MSG
S
S
9
10
175
LS
Loop Header2110D2-5
LOOP ID 2120D2-5
176
178
NM1
LE
1
1
Loop Trailer2110D2-5
23
Trailer
179
180
181
SE
GE
IEA
R
R
R
1
1
1
PAGE 83
271 Segment:
Eligibility
Loop:
Level:
Usage:
Heading
Mandatory
Max Use:
Purpose:
Ref.
Data
Des.
Element
ISA01
I01
Name
Attributes
ID 2/2
ISA02
I02
Authorization Information
AN 10/10
ISA03
I03
ID 2/2
ISA04
I04
Password
Security Information
AN 10/10
This is used for identifying the security information about the interchange sender
or the data in the interchange; the type of information is set by the Security
Information Qualifier (I03)
*From the PBM to Surescripts, this is the Surescripts system assigned
password to the PBM.
*From Surescripts to the Physician System, this is Surescripts defined
password that is used to access the Physician System.
M
ISA05
I05
Interchange ID Qualifier
ID 2/2
ISA06
I06
Mutually Defined
Interchange Sender ID
AN 15/15
Identification code published by the sender for other parties to use as the
receiver ID to route data to them; the sender always codes this value in the
sender ID element
*From the PBM to Surescripts, this is the PBM Participant ID.
*From Surescripts to the Physician System, this is Surescripts Participant ID.
M
ISA07
I05
Interchange ID Qualifier
ID 2/2
PAGE 84
Eligibility
ISA08
I07
Mutually Defined
Interchange Receiver ID
AN 15/15
ISA09
I08
Interchange Date
DT 6/6
TM 4/4
ISA10
I09
Interchange Time
Time of the interchange
*Time format HHDD required.
ISA11
I65
Repetition Separator
M
1/1
Type is not applicable; the repetition separator is a delimiter and not a data
element; this field provides the delimiter used to separate repeated occurrences
of a simple data element or a composite data structure; this value must be
different than the data element separator, component element separator, and the
segment terminator/
*Surescripts recommends using Hex 1F.
ISA12
I11
ID 5/5
ISA13
I12
N0 9/9
ISA14
I13
Acknowledgment Requested
ID 1/1
ISA15
I14
No Acknowledgment Requested
Usage Indicator
ID 1/1
PAGE 85
Eligibility
production or information
ISA16
I15
Production Data
Test Data
AN 1/1
Type is not applicable; the component element separator is a delimiter and not
a data element; this field provides the delimiter used to separate component
data elements within a composite data structure; this value must be different
than the data element separator and the segment terminator.
*Surescripts recommends using Hex 1C.
PAGE 86
271 Segment:
Eligibility
Loop:
Level:
Usage:
Heading
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
The data interchange control number GS06 in this header must be identical to
the same data element in the associated functional group trailer, GE02.
A functional group of related transaction sets, within the scope of X12 standards,
consists of a collection of similar transaction sets enclosed by a functional group
header and a functional group trailer.
Ref.
Data
Des.
Element
GS01
479
Name
Attributes
ID 2/2
GS02
142
AN 2/15
GS03
124
AN 2/15
GS04
373
Date
DT 8/8
TM 4/8
GS05
337
Time
GS06
28
N0 1/9
PAGE 87
Eligibility
The control number should be unique across all functional groups within this
transaction set.
*This number is returned on an AK102 of the 999 acknowledgement if an error
occurs. Providing a unique number will assist in resolving errors and tracking
messages.
M
GS07
455
ID 1/2
Code used in conjunction with Data Element 480 to identify the issuer of the
standard
X
M
GS08
480
AN 1/12
Code indicating the version, release, subrelease, and industry identifier of the
EDI standard being used, including the GS and GE segments; if code in DE455
in GS segment is X, then in DE 480 positions 1-3 are the version number;
positions 4-6 are the release and subrelease, level of the version; and positions
7-12 are the industry or trade association identifiers (optionally assigned by
user); if code in DE455 in GS segment is T, then other formats are allowed
005010X279
Draft Standards Approved for Publication by ASC X12
Procedures Review Board through October 2003, as
published in this implementation guide.
PAGE 88
271 Segment:
Eligibility
Loop:
Level:
Usage:
Heading
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
The transaction set identifier (ST01) is used by the translation routines of the
interchange partners to select the appropriate transaction set definition (e.g., 810
selects the Invoice Transaction Set).
Comments:
Notes:
Use this control segment to mark the start of a transaction set. One ST segment exists for
every transaction set that occurs within a functional group.
Example: ST*271*0001*005010X279~
Ref.
Data
Des.
Element
ST01
143
Name
Attributes
ID 3/3
ST02
329
AN 4/9
Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
The transaction set control numbers in ST02 and SE02 must be identical. This
unique number also aids in error resolution research. Start with a number, for
example 0001, and increment from there. This number must be unique within
a specific group and interchange, but can repeat in other groups and
interchanges.
*This number is returned on an AK202 of the 999 acknowledgement if an error
occurs. Providing a unique number will assist in resolving errors and tracking
messages.
M
ST03
1705
AN 1/35
PAGE 89
Eligibility
PAGE 90
271 Segment:
Eligibility
Loop:
Level:
Usage:
Heading
Mandatory
Max Use:
Purpose:
To define the business hierarchical structure of the transaction set and identify the
business application purpose and reference data, i.e., number, date, and time
Syntax Notes:
Semantic Notes:
BHT03 is the number assigned by the originator to identify the transaction within
the originators business application system.
BHT04 is the date the transaction was created within the business application
system.
BHT05 is the time the transaction was created within the business application
system.
Comments:
Notes:
Use this required segment to start the transaction set and indicate the sequence of the
hierarchical levels of information that will follow in Table 2.
Example: BHT*0022*11*199800114000001*19980101*1401~
Ref.
Data
Des.
Element
BHT01
1005
Name
Attributes
ID 4/4
BHT02
353
ID 2/2
AN 1/50
BHT03
127
Response
Reference Identification
BHT04
373
Date
DT 8/8
TM 4/8
BHT05
337
Time
SURESCRIPTS CONFIDENTIAL AND PROPRIETARY,
NOT TO BE COPIED OR DISTRIBUTED
PAGE 91
Eligibility
PAGE 92
271 Segment:
Loop:
2000A
Level:
Detail
Usage:
Eligibility
Mandatory
Mandatory
Max Use:
Purpose:
Comments:
Notes:
Ref.
Data
Des.
Element
HL01
628
Name
Attributes
Hierarchical ID Number
AN 1/12
HL03
735
ID 1/2
Information Source
Identifies the payer, maintainer, or source of the
information
HL04
736
ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
1
PAGE 93
271 Segment:
Position:
Loop:
2000A
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
To specify the validity of the request and indicate follow-up action authorized
Syntax Notes:
Semantic Notes:
AAA01 designates whether the request is valid or invalid. Code Y indicates that
the code is valid; code N indicates that the code is invalid.
Comments:
Notes:
Use this segment when a request could not be processed at a system or application level
and to indicate what action the originator of the request transaction should take.
Use of this segment at this location in the HL is to identify reasons why a request cannot
be processed based on the entities identified in ISA06, ISA08, GS02 or GS03.
Example: AAA*Y**42*Y~
Ref.
Data
Des.
Element
AAA01
1073
Name
Attributes
ID 1/1
No
Use this code to indicate that the request or an element
in the request is not valid. The transaction has been
rejected as identified by the code in AAA03.
Yes
Use this code to indicate that the request is valid,
however the transaction has been rejected as identified
by the code in AAA03.
AAA03
901
ID 2/2
PAGE 94
41
Eligibility
Authorization/Access Restrictions
Use this code to indicate that the entity identified in
GS02 is not authorized to submit 270 transactions to the
entity identified in either ISA08 or GS03. This is not to be
used to indicate Authorization/Access Restrictions as
related to the Information Source Identified in Loop
2100A.
42
79
AAA04
889
ID 1/1
Resubmission Allowed
PAGE 95
271 Segment:
Loop:
2100A
Level:
Detail
Usage:
Eligibility
Mandatory
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name and/or identification number. This NM1
loop is used to identify the eligibility or benefit information source (e.g., insurance
company, HMO, IPA, employer).
Example: NM1*2B*2*PBM NAME*****PI*87728~
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
ID 1/1
NM103
1035
Person
Organization Name
AN 1/60
NM108
66
ID 1/2
NM109
67
Identification Code
AN 2/80
PAGE 96
271 Segment:
Position:
Loop:
2100A
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
To specify the validity of the request and indicate follow-up action authorized
Syntax Notes:
Semantic Notes:
AAA01 designates whether the request is valid or invalid. Code Y indicates that
the code is valid; code N indicates that the code is invalid.
Comments:
Notes:
Use this segment when a request could not be processed at a system or application level
and to indicate what action the originator of the request transaction should take.
Use this segment to indicate problems in processing the transaction specifically related to
the information source data contained in the original 270 transactions information source
name loop (Loop 2100A) or to indicate that the information source itself is experiencing
system problems.
Example: AAA*Y**42*Y~
Ref.
Data
Des.
Element
AAA01
1073
Name
Attributes
ID 1/1
No
Use this code to indicate that the request or an element
in the request is not valid. The transaction has been
rejected as identified by the code in AAA03.
Yes
Use this code to indicate that the request is valid,
however the transaction has been rejected as identified
by the code in AAA03.
AAA03
901
ID 2/2
PAGE 97
41
Eligibility
Authorization/Access Restrictions
Use this code to indicate that the entity identified in
ISA06 or GS02 is not authorized to submit 270
transactions to the Information Source Identified in Loop
2100A.
*For the Physician System (from Surescripts), 41 would
indicate that the Physician System cannot request
transactions for the identified PBM.
*For Surescripts (from the PBM), 41 would indicate that
Surescripts cannot request eligibility from this PBM.
42
79
80
T4
AAA04
889
ID 1/1
Resubmission Allowed
PAGE 98
271 Segment:
Loop:
2000B
Level:
Detail
Usage:
Eligibility
Optional
Mandatory
Max Use:
Purpose:
Comments:
Notes:
Ref.
Data
Des.
Element
HL01
628
Name
Attributes
Hierarchical ID Number
AN 1/12
HL02
734
AN 1/12
Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
M
HL03
735
ID 1/2
Information Receiver
Identifies the provider or party(ies) who are the recipient(s)
of the information
HL04
736
ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
1
PAGE 99
271 Segment:
Loop:
2100B
Level:
Detail
Usage:
Eligibility
Mandatory
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name and/or identification number. This NM1
loop is used to identify the eligibility/benefit information receiver (e.g., provider, medical
group, IPA, or hospital).
Example: NM1*1P*1*JONES*TIM****XX*111223333~
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
ID 1/1
NM103
1035
Non-Person Entity
AN 1/60
NM104
1036
Name First
AN 1/35
AN 1/25
AN 1/10
NM105
1037
Name Middle
Individual middle name or initial
Use this name only if available and NM102 is 1.
NM107
1039
Name Suffix
Suffix to individual name
Use name suffix only if available and NM102 is 1; e.g., Sr., Jr., or III.
M
NM108
66
ID 1/2
PAGE 100
Eligibility
NM109
67
Identification Code
AN 2/80
PAGE 101
271 Segment:
REF
Loop:
2100B
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
.
Comments:
Notes:
Ref.
Data
Des.
Element
REF01
128
Name
Attributes
ID 2/3
REF02
127
Reference Identification
AN 1/50
REF03
352
Description
AN 1/80
A free-form description to clarify the related data elements and their content
*Not Used for the EO qualifier.
PAGE 102
271 Segment:
Loop:
2100B
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
To specify the validity of the request and indicate follow-up action authorized
Syntax Notes:
Semantic Notes:
AAA01 designates whether the request is valid or invalid. Code Y indicates that
the code is valid; code N indicates that the code is invalid.
Comments:
Notes:
Use this segment when a request could not be processed at a system or application level
and to indicate what action the originator of the request transaction should take.
Use this segment to indicate problems in processing the transaction specifically related to
the information receiver data contained in the original 270 transactions information
receiver name loop (Loop 2100B).
Example: AAA*N**43*C~
Ref.
Data
Des.
Element
AAA01
1073
Name
Attributes
ID 1/1
No
Use this code to indicate that the request or an element
in the request is not valid. The transaction has been
rejected as identified by the code in AAA03.
Yes
Use this code to indicate that the request is valid,
however the transaction has been rejected as identified
by the code in AAA03.
AAA03
901
ID 2/2
41
Authorization/Access Restrictions
*A contract does not exist between this Physician
System and the PBM to exchange eligibility information.
PAGE 103
Eligibility
43
44
45
46
47
48
50
51
79
97
T4
AAA04
889
ID 1/1
Resubmission Allowed
PAGE 104
271 Segment:
HL Subscriber Level
Loop:
2000C
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Comments:
Notes:
Ref.
Data
Des.
Element
HL01
628
Name
Attributes
Hierarchical ID Number
AN 1/12
HL02
734
AN 1/12
Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
M
HL03
735
ID 1/2
Subscriber
Identifies the employee or group member who is covered
for insurance and to whom, or on behalf of whom, the
insurer agrees to pay benefits
Use the subscriber level to identify the insured or
subscriber of the health care coverage. This entity may
or may not be the actual patient.
HL04
736
ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
Because of the hierarchical structure, the code value in the HL04 at the Loop
2000C level should be 1 if a Loop 2000D level (dependent) is associated with
this subscriber. If no Loop 2000D level exists for this subscriber, then the code
value for HL04 should be 0 (zero).
PAGE 105
271 Segment:
Loop:
2000C
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to convey a unique trace or reference number. See the X12 HIPAA
Implementation Guide (Section 1.4.6 Information Linkage) for additional information.
An information source may receive up to two RN segments in each loop 2100C of a 270
transaction and must return each of them in loop 2100C of the 271 transaction with a
value of 2 in TRN01.
If the subscriber is the patient, an information source may add one TRN segment to loop
2100C with a value of 1 in TRN01 and must identify themselves in TRN03.
If this transaction passes through a clearinghouse, the clearinghouse will receive from the
information source the information receivers TRN segment and the clearinghouses TRN
segment with a value of 2 in TRN01. Since the ultimate destination of the transaction is
the information receiver, if the clearinghouse intends on passing their TRN segment to the
information receiver, the clearinghouse must change the value in TRN01 to 1 of their
TRN segment. This must be done since the trace number in the clearinghouses TRN
segment is not actually a referenced transaction trace number to the information receiver.
Example: TRN*2*98175-012547*9877281234*RADIOLOGY~
TRN*2*109834652831*9XYZCLEARH*REALTIME~
TRN*1*209991094361*9ABCINSURE~
The above example represents how an information source would respond. The first TRN
segment was initiated by the information receiver. The second TRN segment was initiated
by the clearinghouse. The third TRN segment was initiated by the information source.
TRN*2*98175-012547*9877281234*RADIOLOGY~
TRN*1*109834652831*9XYZCLEARH*REALTIME~
TRN*1*209991094361*9ABCINSURE~
The above example represents how a clearinghouse would respond to the same set of
TRN segments if the clearinghouse intends to pass their TRN segment on to the
information receiver. If the clearinghouse does not intend to pass their TRN segment on to
the information receiver, only the first and third TRN segments in the example would be
sent.
Data
Des.
Element
Name
Attributes
PAGE 106
TRN01
481
Eligibility
ID 1/2
TRN02
127
Reference Identification
AN 1/50
TRN03
509
AN 10/10
TRN04
127
Reference Identification
AN 1/50
PAGE 107
271 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name and/or identification number. This NM1
loop is used to identify the insured or subscriber.
* See the Patient_Match_Verification for more details.
Example: NM1*IL*1*SMITH*ROBERT*B***MI*33399999~
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
Insured or Subscriber
ID 1/1
AN 1/60
NM103
1035
Person
Required unless a rejection response is generated and this element was not
valued in the request.
*This data is to be returned from the PBM payer system.
O
NM104
1036
Name First
AN 1/35
NM105
1037
Name Middle
AN 1/25
PAGE 108
Eligibility
NM107
1039
Name Suffix
AN 1/10
NM108
66
ID 1/2
NM109
67
Identification Code
AN 2/80
PAGE 109
271 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Notes:
Ref.
Data
Des.
Element
REF01
128
Name
Attributes
ID 2/3
49
SY
EJ
M
REF02
127
Reference Identification
AN 1/50
REF03
352
Description
AN 1/80
A free-form description to clarify the related data elements and their content
PAGE 110
271 Segment:
N3 Subscriber Address
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes :
Semantic Notes :
Comments :
Notes:
Ref.
Data
Des.
Element
N301
166
Name
Attributes
Address Information
AN 1/55
AN 1/55
Address information
Use this information for the first line of the address information.
*This data is to be returned from the PBM payer system.
O
N302
166
Address Information
Address information
Use this information for the second line of the address information.
Required if a second address line exists.
PAGE 111
271 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to identify the city, state and ZIP Code for the subscriber.
Use of this segment is required if the transaction is not rejected and address information is
available from the information sources database.
Do not return address information from the 270 request.
Example: N4*NEW YORK*NY*10003~
* See the Patient_Match_Verification for more details.
Ref.
Data
Des.
Element
N401
19
Name
City Name
Attributes
O
AN 2/30
ID 2/2
N402
156
N403
116
Postal Code
ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)
Required when the address is in the United States of America, including its
territories, or Canada, or when a postal code exists for the country in N404. If
not required by this implementation guide, do not send.
*This data is to be returned from the PBM payer system.
O
N404
26
Country Code
ID 2/3
PAGE 112
271 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
To specify the validity of the request and indicate follow-up action authorized
Syntax Notes:
Semantic Notes:
AAA01 designates whether the request is valid or invalid. Code Y indicates that
the code is valid; code N indicates that the code is invalid.
Comments:
Notes:
Use this segment when a request could not be processed at a system or application level
and to indicate what action the originator of the request transaction should take.
Use this segment to indicate problems in processing the transaction specifically related to
the data contained in the original 270 transactions subscriber name loop (Loop 2100C).
Example: AAA*N**72*C~
Ref.
Data
Des.
Element
AAA01
1073
Name
Attributes
ID 1/1
No
Use this code to indicate that the request or an element
in the request is not valid. The transaction has been
rejected as identified by the code in AAA03.
Yes
Use this code to indicate that the request is valid,
however the transaction has been rejected as identified
by the code in AAA03.
AAA03
901
ID 2/2
35
Out of Network
42
PAGE 113
Eligibility
AAA04
889
43
45
47
48
49
51
52
56
Inappropriate Date
57
58
Invalid/Missing Date-of-Birth
60
61
62
63
71
Patient Birth Date Does Not Match That for the Patient on
the Database
72
Invalid/Missing Subscriber/Insured ID
73
74
75
76
78
ID 1/1
Resubmission Allowed
Use only when AAA03 is 42.
PAGE 114
Eligibility
PAGE 115
271 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to convey the birth date or gender demographic information for the
subscriber.
Use this segment only if the subscriber is the patient and if this information is available
from the Information Sources database unless a rejection response is generated and the
elements were not valued in the request.
*See the Patient Match Verification for more details.
Example: DMG*D8*19430917*M~
Ref.
Data
Des.
Element
DMG01
1250
Name
Attributes
ID 2/3
Code indicating the date format, time format, or date and time format
Use this code to indicate the format of the date of birth that follows in DMG02.
D8
O
DMG02
1251
AN 1/35
DMG03
1068
Gender Code
ID 1/1
Female
Male
Unknown
PAGE 116
271 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Required when acknowledging a change in the identifying elements for the subscriber
from those submitted in the 270 or the Birth Sequence Number submitted in INS17 of the
270 was used to locate the Subscriber.
If not required by this implementation guide, do not send.
Example:
INS*Y*18*001*25~
See X12 Guide for more information.
*Surescripts only uses this segment to indicate if any of the identifying elements for the
subscriber have been changed from those submitted in the 270.
Ref.
Data
Des.
Element
INS01
1073
Name
Attributes
ID 1/1
INS02
1069
Yes
ID 2/2
INS03
875
Self
ID 3/3
INS04
1203
Change
ID 2/3
PAGE 117
Eligibility
identify a specific employee. Such elements are first
name, last name, social security number, date of birth, and
employee identification number
Use this code to indicate that a change has been made
to the primary elements that identify a specific person.
Such elements are first name, last name, date of birth,
identification numbers, and address.
PAGE 118
271 Segment:
Loop:
2100C
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
DTP02 is the date or time or period format that will appear in DTP03.
Comments:
Notes:
Use this segment to convey any relevant dates. The dates represented may be in the
past, the current date, or a future date. The dates may also be a single date or a span of
dates. Which date(s) to use is determined by the format qualifier in DTP02.
When using code 291 (Plan) at this level, it is implied that these dates apply to all of the
Eligibility or Benefit Information (EB) loops that follow.
Example: DTP*291*D8*19950818~
*Surescripts recommends echoing back the date sent in the 270 for this DTP Segment.
Ref.
Data
Des.
Element
DTP01
374
Name
Attributes
Date/Time Qualifier
ID 3/3
ID 2/3
DTP02
1250
Plan
Code indicating the date format, time format, or date and time format
Use this code to specify the format of the date(s)/time(s) that follow in the next
data element.
D8
RD8
DTP03
1251
AN 1/35
PAGE 119
271 Segment:
Loop:
2110C1
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
See X12 Guide. Use this segment to begin the eligibility/benefit information looping
structure. The EB segment is used to convey the specific eligibility or benefit information
for the entity identified.
If the transaction is rejected, and the MESSAGE field is utilized in the EB segment, then
the segment will exist with a V- Cannot process, and the associated message.
Example: EB*1**30**HEALTH PLAN NAME~
Ref.
Data
Des.
Element
EB01
1390
Name
Attributes
ID 1/2
Active Coverage
Inactive
*If the member is inactive, then no other EB loops are
required to be sent.
EB03
1365
Cannot Process
ID 1/2
ID 1/3
EB04
1336
47
CP
MC
Medicaid
MP
Medicare Primary
OT
PAGE 120
EB05
1204
Eligibility
AN
1/50
EB07
782
Monetary Amount
R 1/18
Monetary amount
INDUSTRY: Benefit Amount
Use this monetary amount as qualified by EB01.
Use if eligibility or benefit must be qualified by a monetary amount;
e.g., deductible, co-payment.
* Surescripts is utilizing this field for Out of Pocket Accumulator. EB01 set to G.
PAGE 121
271 Segment:
Loop:
2110C1
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
REF01
128
Name
Attributes
ID 2/3
Plan ID
6P
Group Number
ALS
Alternate List ID
CLI
Coverage List ID
FO
IG
N6
REF02
127
Reference Identification
AN 1/50
PAGE 122
REF03
352
Description
Eligibility
AN 1/80
A free-form description to clarify the related data elements and their content
*This element should only be used for Group Name and/or PCN number.
REF01=6P, This is the group name..
REF01=N6, This is the PCN Number
PAGE 123
271 Segment:
Loop:
2110C1
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
20
Purpose:
DTP02 is the date or time or period format that will appear in DTP03.
Comments:
Notes:
When using the DTP segment in the 2110C loop this date applies only to the 2110C
Eligibility or Benefit Information (EB) loop in which it is located.
If a DTP segment with the same DTP01 value is present in the 2100C loop, the date is
overridden for only this 2110C Eligibility or Benefit Information (EB) loop.
Example: DTP*291*RD8*20100101-20101231~
*Surescripts recommends sending back the date range of the health plan benefit for this
patients coverage.
Ref.
Data
Des.
Element
DTP01
374
Name
Attributes
Date/Time Qualifier
ID 3/3
ID 2/3
DTP02
1250
Plan
Code indicating the date format, time format, or date and time format
Use this code to specify the format of the date(s)/time(s) that follow in the next
data element.
D8
RD8
DTP03
1251
AN 1/35
PAGE 124
271 Segment:
Loop:
2110C1
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
To specify the validity of the request and indicate follow-up action authorized
Syntax Notes:
Semantic Notes:
AAA01 designates whether the request is valid or invalid. Code "Y" indicates that
the code is valid; code "N" indicates that the code is invalid.
Comments:
Notes:
Use this segment when a request could not be processed at a system or application level
and to indicate what action the originator of the request transaction should take.
Use this segment to indicate problems in processing the transaction specifically related to
specific eligibility/benefit inquiry data contained in the original 270 transaction's subscriber
eligibility/benefit inquiry information loop (Loop 2110C).
Example: AAA*N**70*C~
Ref.
Data
Des.
Element
AAA01
1073
Name
Attributes
ID 1/1
No
Use this code to indicate that the request or an element
in the request is not valid. The transaction has been
rejected as identified by the code in AAA03.
Yes
Use this code to indicate that the request is valid,
however the transaction has been rejected as identified
by the code in AAA03.
AAA03
901
ID 2/2
15
33
Input Errors
Use this code only when data is present in this transaction
and no other Reject Reason Code is valid for describing the
error. Detail of the error must be supplied in the MSG
segment of the 2110C loop containing this Reject Reason
Code.
52
53
PAGE 125
Eligibility
54
55
Inappropriate Product/Service ID
56
Inappropriate Date
57
60
61
62
63
69
70
AAA04
889
ID 1/1
Resubmission Allowed
PAGE 126
271 Segment:
Loop:
2110C1
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
10
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
MSG02 is not related to the specific characteristics of a printer, but identifies top
of page, advance a line, etc.
If MSG02 is "AA - Advance the specified number of lines before print" then
MSG03 is required.
Notes:
Free form text or description fields are not recommended because they require human
interpretation.
Under no circumstances can an information source use the MSG segment to relay
information that can be sent using codified information in existing data elements. If the
need exists to use the MSG segment, it is highly recommended that the entity needing to
use the MSG segment approach X12N with data maintenance to solve the business need
without the use of the MSG segment.
Benefit Disclaimers are strongly discouraged. See X12 Guide (Section 1.4.11 Disclaimers
Within the Transaction). Under no circumstances is more than one MSG segment to be
used for a Benefit Disclaimer per individual response.
* This free text field will be populated by Surescripts as a hint to the requester on what
fields would assist in identifying the patient. This is sent if patient is not found and one or
more of the following fields are missing; first name, last name, zip code or date of birth.
Example: MSG*Unable to find patient in Surescripts system. Supplying some of these
fields will help find a match: patient zip code~
Ref.
Data
Des.
Element
MSG01
933
Name
Free-Form Message Text
Attributes
M
AN 1/264
PAGE 127
271 Segment:
LS Loop Header
Loop:
2110C1
Level:
Detail
Usage:
Optional
Optional
Max Use:
Purpose:
Notes:
Eligibility
Use this segment to identify the beginning of the Subscriber Benefit Related Entity Name
loop. Because both the subscribers name loop and this loop begin with NM1 segments,
the LS and LE segments are used to differentiate these two loops. Required if Loop
2120C is used.
Example: LS*2120~
Ref.
Data
Des.
Element
LS01
447
Name
Loop Identifier Code
Attributes
M
AN 1/6
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
This data element must have the value of 2120".
PAGE 128
271 Segment:
Loop:
2120C1
Level:
Detail
Usage:
Eligibility
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name and/or identification number. This NM1
loop is used to identify a provider (such as the primary care provider), an individual,
another payer, or another information source when applicable to the eligibility response.
Example: NM1*SEP*2*SECONDARY PAYER NAME*****PI*PAYERPARTID~
Data Element Summary
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
PRP
Primary Payer
SEP
Secondary Payer
TTP
Tertiary Payer
ID 1/1
AN 1/60
Person
Non-Person Entity
*Surescripts recommends using 2
NM103
1035
Use this name for the organization name if the entity type qualifier is a nonperson entity. Otherwise, this will be the individuals last name.
O
NM104
1036
Name First
AN 1/35
AN 1/25
AN 1/10
NM105
1037
Name Middle
Individual middle name or initial
Use this name only if available and NM102 is "1".
NM107
1039
Name Suffix
Suffix to individual name
Use name suffix only if available and NM102 is "1"; e.g., Sr., Jr., or III.
PAGE 129
NM108
66
Eligibility
ID 1/2
NM109
67
Payer Identification
Identification Code
AN 2/80
PAGE 130
271 Segment:
LE Loop Trailer
Loop:
2110C1
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to identify the end of the Subscriber Benefit Related Entity Name loop.
Because both the subscribers name loop and this loop begin with NM1 segments, the LS
and LE segments are used to differentiate these two loops. Required if Loop 2120C is
used.
Example: LE*2120~
Ref.
Data
Des.
Element
LE01
447
Name
Attributes
AN 1/6
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
This data element must have the value of 2120".
Notes:
Use this segment to identify the end of the Subscriber Benefit Related Entity Name loop.
Because both the subscribers name loop and this loop begin with NM1 segments, the LS
and LE segments are used to differentiate these two loops. Required if Loop 2120C is
used.
Example: LE*2120~
Ref.
Data
Des.
Element
LE01
447
Name
Loop Identifier Code
Attributes
M
AN 1/6
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
This data element must have the value of 2120".
PAGE 131
271 Segment:
Loop:
2110C2-5
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
See X12 Guide. Use this segment to begin the eligibility/benefit information looping
structure. The EB segment is used to convey the specific eligibility or benefit information
for the entity identified.
*If the previous EB loop EB 30 was set to 6 for not active, then the loop is not required.
Example:
EB*1**88**RETAIL HEALTH PLAN NAME ~
EB*1**90**MAIL ORDER HEALTH PLAN NAME ~
EB*1****SPECIALTY HEALTH PLAN NAME ~
MSG*SPECIALTY PHARMACY~
EB*1****LTC HEALTH PLAN NAME ~
MSG*LTC~
Ref.
Data
Des.
Element
EB01
1390
Name
Attributes
ID 1/2
Active Coverage
*Covered
EB03
1365
Non-Covered
ID 1/2
EB04
1336
88
90
Empty/Null
ID 1/3
PAGE 132
Eligibility
Use if available.
* See X12 guide for additional qualifiers.
EB05
1204
47
CP
MC
Medicaid
MP
Medicare Primary
OT
AN 1/50
EB07
782
Monetary Amount
R 1/18
Monetary amount
INDUSTRY: Benefit Amount
Use this monetary amount as qualified by EB01.
Use if eligibility or benefit must be qualified by a monetary amount;
e.g., deductible, co-payment.
* Surescripts is utilizing this field for Out of Pocket Accumulator. EB01 set to G.
PAGE 133
271 Segment:
Loop:
2110C2-5
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
20
Purpose:
DTP02 is the date or time or period format that will appear in DTP03.
Comments:
Notes:
When using the DTP segment in the 2110C loop this date applies only to the 2110C
Eligibility or Benefit Information (EB) loop in which it is located.
If a DTP segment with the same DTP01 value is present in the 2100C loop, the date is
overridden for only this 2110C Eligibility or Benefit Information (EB) loop.
Example: DTP*291*RD8*20100101-20101231~
*Surescripts recommends sending back the date range of the health plan benefit for this
patients coverage.
Ref.
Data
Des.
Element
DTP01
374
Name
Attributes
Date/Time Qualifier
ID 3/3
ID 2/3
DTP02
1250
Plan
Code indicating the date format, time format, or date and time format
Use this code to specify the format of the date(s)/time(s) that follow in the next
data element.
D8
RD8
DTP03
1251
AN 1/35
PAGE 134
271 Segment:
Loop:
2110C2-5
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
To specify the validity of the request and indicate follow-up action authorized
Syntax Notes:
Semantic Notes:
AAA01 designates whether the request is valid or invalid. Code "Y" indicates that
the code is valid; code "N" indicates that the code is invalid.
Comments:
Notes:
Use this segment when a request could not be processed at a system or application level
and to indicate what action the originator of the request transaction should take.
Use this segment to indicate problems in processing the transaction specifically related to
specific eligibility/benefit inquiry data contained in the original 270 transaction's subscriber
eligibility/benefit inquiry information loop (Loop 2110C).
Example: AAA*N**70*C~
Ref.
Data
Des.
Element
AAA01
1073
Name
Attributes
ID 1/1
No
Use this code to indicate that the request or an element
in the request is not valid. The transaction has been
rejected as identified by the code in AAA03.
Yes
Use this code to indicate that the request is valid;
however, the transaction has been rejected as identified
by the code in AAA03.
AAA03
901
ID 2/2
15
33
Input Errors
Use this code only when data is present in this transaction
and no other Reject Reason Code is valid for describing the
error. Detail of the error must be supplied in the MSG
segment of the 2110C loop containing this Reject Reason
Code.
52
53
PAGE 135
Eligibility
54
55
Inappropriate Product/Service ID
56
Inappropriate Date
57
60
61
62
63
69
70
AAA04
889
ID 1/1
Resubmission Allowed
PAGE 136
Eligibility
271 Segment:
Loop:
2110C2-5
Level:
Detail
Usage:
Optional
Optional
Max Use:
10
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
MSG02 is not related to the specific characteristics of a printer, but identifies top
of page, advance a line, etc.
If MSG02 is "AA - Advance the specified number of lines before print" then
MSG03 is required.
Notes:
Free form text or description fields are not recommended because they require human
interpretation.
Under no circumstances can an information source use the MSG segment to relay
information that can be sent using codified information in existing data elements. If the
need exists to use the MSG segment, it is highly recommended that the entity needing to
use the MSG segment approach X12N with data maintenance to solve the business need
without the use of the MSG segment.
Benefit Disclaimers are strongly discouraged. See section 1.3.10 Disclaimers Within the
Transaction. Under no circumstances is more than one MSG segment to be used for a
Benefit Disclaimer per individual response.
* This free text is used for Specialty Pharmacy and LTC since there is not a service type
code available to use. The text SPECIALTY PHARMACY will indicate this EB loop is for
Specialty Pharmacy and the text LTC will indicate this is for Long Term Care.
Example: MSG*SPECIALTY PHARMACY~
MSG*LTC~
Ref.
Data
Des.
Element
MSG01
933
Name
Free-Form Message Text
Attributes
M
AN 1/264
PAGE 137
271 Segment:
LS Loop Header
Loop:
2110C2-5
Level:
Detail
Usage:
Optional
Optional
Max Use:
Purpose:
Notes:
Eligibility
Use this segment to identify the beginning of the Subscriber Benefit Related Entity Name
loop. Because both the subscribers name loop and this loop begin with NM1 segments,
the LS and LE segments are used to differentiate these two loops. Required if Loop
2120C is used.
Example: LS*2120~
Ref.
Data
Des.
Element
LS01
447
Name
Loop Identifier Code
Attributes
M
AN 1/6
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
This data element must have the value of 2120".
PAGE 138
271 Segment:
Loop:
2120C2-5
Level:
Detail
Usage:
Eligibility
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name and/or identification number. This NM1
loop is used to identify a provider (such as the primary care provider), an individual,
another payer, or another information source when applicable to the eligibility response.
Example: NM1*SEP*2*SECONDARY PAYER NAME*****PI*PAYERPARTID~
Example: NM1*13*2*PHARMACY ABC*****SV*NCPDPID~
Data Element Summary
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
PRP
Primary Payer
SEP
Secondary Payer
TTP
Tertiary Payer
ID 1/1
AN 1/60
Person
Non-Person Entity
*Surescripts recommends using 2
NM103
1035
Use this name for the organization name if the entity type qualifier is a nonperson entity. Otherwise, this will be the individuals last name.
O
NM104
1036
Name First
AN 1/35
AN 1/25
NM105
1037
Name Middle
Individual middle name or initial
Use this name only if available and NM102 is "1".
PAGE 139
NM107
1039
Eligibility
Name Suffix
AN 1/10
NM108
66
ID 1/2
PI
O
NM109
67
Payer Identification
Identification Code
AN 2/80
PAGE 140
271 Segment:
LE Loop Trailer
Loop:
2110C2-5
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to identify the end of the Subscriber Benefit Related Entity Name loop.
Because both the subscribers name loop and this loop begin with NM1 segments, the LS
and LE segments are used to differentiate these two loops. Required if Loop 2120C is
used.
Example: LE*2120~
Ref.
Data
Des.
Element
LE01
447
Name
Attributes
AN 1/6
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
This data element must have the value of 2120".
Notes:
Use this segment to identify the end of the Subscriber Benefit Related Entity Name loop.
Because both the subscribers name loop and this loop begin with NM1 segments, the LS
and LE segments are used to differentiate these two loops. Required if Loop 2120C is
used.
Example: LE*2120~
Ref.
Data
Des.
Element
LE01
447
Name
Loop Identifier Code
Attributes
M
AN 1/6
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
This data element must have the value of 2120".
PAGE 141
271 Segment:
Eligibility
HL Dependent Level
Loop:
2000D
Optional
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Comments:
Notes:
Since Surescripts uniquely identifies each patient, the subscriber level should be used instead of the
dependant level regardless of whether the patient is a subscriber or dependent. However, receivers of
the 270 should be able to handle patients at the dependent level since the standard allows it.
Ref.
Data
Des.
Element
HL01
628
Name
Attributes
Hierarchical ID Number
AN 1/12
HL02
734
AN 1/12
Identification number of the next higher hierarchical data segment that the data
segment being described is subordinate to
M
HL03
735
ID 1/2
Dependent
Identifies the individual who is affiliated with the
subscriber, such as spouse, child, etc., and therefore may
be entitled to benefits
Use the dependent level to identify an individual(s) who
may be a dependent of the subscriber/insured. This
entity may or may not be the actual patient.
PAGE 142
HL04
736
Eligibility
ID 1/1
Code indicating if there are hierarchical child data segments subordinate to the
level being described
Use this code to indicate whether there are additional hierarchical levels
subordinate to the current hierarchical level.
Because of the hierarchical structure, and because no subordinate HL levels
exist, the code value in the HL04 at the Loop 2000D level should be "0" (zero).
0
PAGE 143
271 Segment:
Eligibility
Loop:
2000D
Optional
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to convey a unique trace or reference number. See the X12 HIPAA
Implementation Guide (Section 1.4.6 Information Linkage) for additional information.
An information source may receive up to two TRN segments in each loop 2100D of a 270
transaction and must return each of them in loop 2100D of the 271 transaction with a
value of "2" in TRN01.
An information source may add one TRN segment to loop 2100D with a value of "1" in
TRN01 and must identify themselves in TRN03.
If this transaction passes through a clearinghouse, the clearinghouse will receive from the
information source the information receiver's TRN segment and the clearinghouse's TRN
segment with a value of "2" in TRN01. Since the ultimate destination of the transaction is
the information receiver, if the clearinghouse intends to pass their TRN segment to the
information receiver, the clearinghouse must change the value in TRN01 to "1" of their
TRN segment. This must be done since the trace number in the clearinghouse's TRN
segment is not actually a referenced transaction trace number to the information receiver.
Example: TRN*2*98175-012547*9877281234*RADIOLOGY~
TRN*2*109834652831*9XYZCLEARH*REALTIME~
TRN*1*209991094361*9ABCINSURE~
The above example represents how an information source would respond. The first TRN
segment was initiated by the information receiver. The second TRN segment was initiated
by the clearinghouse. The third TRN segment was initiated by the information source.
TRN*2*98175-012547*9877281234*RADIOLOGY~
TRN*1*109834652831*9XYZCLEARH*REALTIME~
TRN*1*209991094361*9ABCINSURE~
The above example represents how a clearinghouse would respond to the same set of
TRN segments if the clearinghouse intends to pass their TRN segment on to the
information receiver. If the clearinghouse does not intend to pass their TRN segment on to
the information receiver, only the first and third TRN segments in the example would be
sent.
PAGE 144
Eligibility
Ref.
Data
Des.
Element
TRN01
481
Name
Attributes
ID 1/2
TRN02
127
Reference Identification
AN 1/50
TRN03
509
AN 10/10
TRN04
127
Reference Identification
AN 1/50
PAGE 145
271 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name and/or identification number. This NM1
loop is used to identify the dependent of an insured or subscriber.
*See the Patient Match Verification for more details.
Example: NM1*03*SMITH*MARY LOU*R~
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
Dependent
ID 1/1
AN 1/60
NM103
1035
Person
Required unless a rejection response is generated and this element was not
valued in the request.
*This data is to be returned from the PBM payer system.
O
NM104
1036
Name First
AN 1/35
NM105
1037
Name Middle
AN 1/25
PAGE 146
Eligibility
NM107
1039
Name Suffix
AN 1/10
PAGE 147
271 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
REF01
128
Name
Attributes
ID 2/3
49
SY
EJ
M
REF02
127
Reference Identification
AN 1/50
REF03
352
Description
AN 1/80
A free-form description to clarify the related data elements and their content
PAGE 148
271 Segment:
Eligibility
N3 Dependent Address
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
N301
166
Name
Address Information
Attributes
M
AN 1/55
AN 1/55
Address information
Use this information for the first line of the address information
*This data is to be returned from the PBM payer system..
O
N302
166
Address Information
Address information
Use this information for the second line of the address information.
Required if a second address line exists.
PAGE 149
271 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to identify the city, state and ZIP Code for a dependent.
Use of this segment is required if the transaction is not rejected and address information is
available from the information source's database.
Do not return address information from the 270 request.
Example: N4*NEW YORK*NY*10003~
* See the Patient Match Verification for more details.
Ref.
Data
Des.
Element
N401
19
Name
City Name
Attributes
O
AN 2/30
ID 2/2
N402
156
N403
116
Postal Code
ID 3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)
Required when the address is in the United States of America, including its
territories, or Canada, or when a postal code exists for the country in N404. If
not required by this implementation guide, do not send.
*This data is to be returned from the PBM payer system
O
N404
26
Country Code
ID 2/3
PAGE 150
271 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
To specify the validity of the request and indicate follow-up action authorized
Syntax Notes:
Semantic Notes:
AAA01 designates whether the request is valid or invalid. Code "Y" indicates that
the code is valid; code "N" indicates that the code is invalid.
Comments:
Notes:
Use this segment when a request could not be processed at a system or application level
and to indicate what action the originator of the request transaction should take.
Use this segment to indicate problems in processing the transaction specifically related to
the data contained in the original 270 transaction's dependent name loop (Loop 2100D).
Example: AAA*N**72*C~
Ref.
Data
Des.
Element
AAA01
1073
Name
Attributes
ID 1/1
ID 2/2
AAA03
901
No
Yes
Use this code for the reason why the transaction was unable to be processed
successfully. This may indicate problems with the system, the application, or the
data content.
15
35
Out of Network
Use this code to indicate that the dependent is not
in the Network of the provider identified in the 2100B
NM1 segment, or the 2100B/2100D PRV segment if
present, in the 270 transaction
42
43
PAGE 151
AAA04
889
Eligibility
45
47
48
49
51
52
56
Inappropriate Date
57
58
Invalid/Missing Date-of-Birth
Code 58 may not be returned if the information source has
located an individual and the Birth Date does not match; use
code 71 instead.
60
61
62
63
64
Invalid/Missing Patient ID
65
66
67
68
71
Patient Birth Date Does Not Match That for the Patient on
the Database
77
ID 1/1
Resubmission Allowed
Use only when AAA03 is "42".
PAGE 152
271 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to convey the birth date or gender demographic information for the
dependent.
Required if this is available from the Information Source's database unless a rejection
response is generated and this element was not valued in the request.
*See the Patient Match Verification for more details.
Example: DMG*D8*19750616*M~
Ref.
Data
Des.
Element
DMG01
1250
Name
Attributes
ID 2/3
Code indicating the date format, time format, or date and time format
Use this code to indicate the format of the date of birth that follows in DMG02.
D8
O
DMG02
1251
AN 1/35
DMG03
1068
Gender Code
ID 1/1
Female
Male
Unknown
PAGE 153
271 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
INS01 indicates status of the insured. A "Y" value indicates the insured is a
subscriber: an "N" value indicates the insured is a dependent.
INS17 is the number assigned to each family member born with the same birth
date. This number identifies birth sequence for multiple births allowing proper
tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
Comments:
Notes:
Required when the Dependent is the patient unless a rejection response is generated
with a 2100D or 2110D AAA segment and this segment was not sent in the request. If
not required by this implementation guide, may be provided at senders discretion but
cannot be required by the receiver.
This segment may also be used to identify that the information source has changed some
of the identifying elements for the dependent that the information receiver submitted in
the original 270 transaction.
Example:
INSN193~
See X12 Guide for more information.
Data Element Summary
Ref.
Data
Des.
Element
INS01
1073
Name
Attributes
ID 1/1
ID 2/2
INS02
1069
No
Spouse
19
Child
Dependent between the ages of 0 and 19; age
qualifications may vary depending on policy
21
Unknown
Use this code only if relationship information is not
available and there is a need to use data elements
INS03, INS04, INS09, INS10 or INS17.
34
O
INS03
875
Other Adult
ID 3/3
PAGE 154
001
O
INS04
1203
Eligibility
Change
ID 2/3
PAGE 155
271 Segment:
Eligibility
Loop:
2100D
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
DTP02 is the date or time or period format that will appear in DTP03.
Comments:
Notes:
Use this segment to convey any relevant dates. The dates represented may be in the
past, the current date, or a future date. The dates may also be a single date or a span of
dates. Which date(s) to use is determined by the format qualifier in DTP02.
When using code 291 (Plan) at this level, it is implied that these dates apply to all of the
Eligibility or Benefit Information (EB) loops that follow.
Example: DTP*291*D8*19950818~
Ref.
Data
Des.
Element
DTP01
374
Name
Attributes
Date/Time Qualifier
ID 3/3
ID 2/3
DTP02
1250
Plan
Code indicating the date format, time format, or date and time format
Use this code to specify the format of the date(s)/time(s) that follow in the next
data element.
D8
RD8
M
DTP03
1251
AN 1/35
PAGE 156
271 Segment:
Eligibility
Loop:
2110D1
Optional
Level:
Summary
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
See X12 Guide. Use this segment to begin the eligibility/benefit information looping
structure. The EB segment is used to convey the specific eligibility or benefit information
for the entity identified.
If the transaction is rejected, and the MESSAGE field is utilized in the EB segment, then
the segment will exist with a V- Cannot process, and the associated message.
Example: EB*1**30**HEALTH PLAN NAME~
Ref.
Data
Des.
Element
EB01
1390
Name
Attributes
ID 1/2
ID 1/2
ID 1/3
EB03
1365
Active Coverage
Inactive
Cannot Process
EB04
1336
Code identifying the type of insurance policy within a specific insurance program
Use if available.
* See X12 guide for additional qualifiers.
47
CP
MC
Medicaid
MP
Medicare Primary
OT
PAGE 157
EB05
1204
Eligibility
AN 1/50
PAGE 158
271 Segment:
Loop:
2110D1
Level:
Detail
Usage:
Eligibility
Mandatory
Optional
Max Use:
Purpose:
Syntax Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
REF01
128
Name
Attributes
ID 2/3
Plan ID
6P
Group Number
ALS
Alternate List ID
CLI
Coverage List ID
FO
IG
N6
REF02
127
Reference Identification
AN 1/50
REF03
352
Description
AN 1/80
A free-form description to clarify the related data elements and their content
PAGE 159
Eligibility
PAGE 160
271 Segment:
Loop:
2110D1
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
20
Purpose:
Semantic Notes:
Comments:
Notes:
When using the DTP segment in the 2110D loop this date applies only to the 2110D
Eligibility or Benefit Information (EB) loop in which it is located.
If a DTP segment with the same DTP01 value is present in the 2100D loop, the date is
overridden for only this 2110D Eligibility or Benefit Information (EB) loop.
Example: DTP*291*RD8*20100101-20101231~
*Surescripts recommends sending back the date range of the health plan benefit for this
patients coverage.
Ref.
Data
Des.
Element
DTP01
374
Name
Attributes
Date/Time Qualifier
ID 3/3
ID 2/3
DTP02
1250
Plan
Code indicating the date format, time format, or date and time format
Use this code to specify the format of the date(s)/time(s) that follow in the next
data element.
D8
RD8
DTP03
1251
AN 1/35
PAGE 161
271 Segment:
Loop:
2110D1
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
To specify the validity of the request and indicate follow-up action authorized
Syntax Notes:
Semantic Notes:
AAA01 designates whether the request is valid or invalid. Code "Y" indicates that
the code is valid; code "N" indicates that the code is invalid.
Comments:
Notes:
Use this segment when a request could not be processed at a system or application level
and to indicate what action the originator of the request transaction should take.
Use this segment to indicate problems in processing the transaction specifically related to
specific eligibility/benefit inquiry data contained in the original 270 transaction's dependent
eligibility/benefit inquiry information loop (Loop 2110D).
Example: AAA*N**70*C~
Data Element Summary
Ref.
Data
Des.
Element
AAA01
1073
Name
Attributes
ID 1/1
No
Use this code to indicate that the request or an element
in the request is not valid. The transaction has been
rejected as identified by the code in AAA03.
Yes
Use this code to indicate that the request is valid;
however, the transaction has been rejected as identified
by the code in AAA03.
AAA03
901
ID 2/2
15
33
Input Errors
Use this code only when data is present in this transaction
and no other Reject Reason Code is valid for describing the
error. Detail of the error must be supplied in the MSG
segment of the 2110D loop containing this Reject Reason
Code.
52
53
PAGE 162
AAA04
889
Eligibility
54
55
Inappropriate Product/Service ID
56
Inappropriate Date
57
60
61
62
63
69
70
ID 1/1
Resubmission Allowed
PAGE 163
271 Segment:
Eligibility
Loop:
2110D1
Mandatory
Level:
Summary
Usage:
Optional
Max Use:
10
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
MSG02 is not related to the specific characteristics of a printer, but identifies top
of page, advance a line, etc.
If MSG02 is "AA - Advance the specified number of lines before print" then
MSG03 is required.
Notes:
Free form text or description fields are not recommended because they require human
interpretation.
Under no circumstances can an information source use the MSG segment to relay
information that can be sent using codified information in existing data elements. If the
need exists to use the MSG segment, it is highly recommended that the entity needing to
use the MSG segment approach X12N with data maintenance to solve the business need
without the use of the MSG segment.
Benefit Disclaimers are strongly discouraged. See the X12 Guide, Section 1.4.11
Disclaimers Within the Transaction. Under no circumstances is more than one MSG
segment to be used for a Benefit Disclaimer per individual response.
* This free text field will be populated by Surescripts as a hint to the requester on what
fields would assist in identifying the patient. This is sent if patient is not found and one or
more of the following fields are missing; first name, last name, zip code or date of birth.
Example: MSG* Unable to find patient in Surescripts system. Supplying some of these
fields will help find a match: patient zip code ~
Ref.
Data
Des.
Element
MSG01
933
Name
Free-Form Message Text
Attributes
M
AN 1/264
PAGE 164
271 Segment:
LS Loop Header
Loop:
2110D1
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to identify the beginning of the Dependent Benefit Related Entity Name
loop. Because both the subscribers name loop and this loop begin with NM1 segments,
the LS and LE segments are used to differentiate these two loops. Required if Loop
2120D is used
Example: LS*2120~
Ref.
Data
Des.
Element
LS01
447
Name
Loop Identifier Code
Attributes
M
AN 1/6
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
This data element must have the value of 2120".
PAGE 165
271 Segment:
Loop:
2120D1
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name and/or identification number. This NM1
loop is used to identify a provider (such as the primary care provider), an individual,
another payer, or another information source when applicable to the eligibility response.
Example: NM1*SEP*2*SECONDARY PAYER NAME*****PI*PAYERPARTID~
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
PRP
Primary Payer
SEP
Secondary Payer
TTP
Tertiary Payer
ID 1/1
AN 1/60
NM103
1035
Person
Non-Person Entity
Use this name for the organization name if the entity type qualifier is a nonperson entity. Otherwise, this will be the individuals last name.
O
NM104
1036
Name First
AN 1/35
AN 1/25
AN 1/10
NM105
1037
Name Middle
Individual middle name or initial
Use this name only if available and NM102 is "1".
NM107
1039
Name Suffix
Suffix to individual name
Use name suffix only if available and NM102 is "1"; e.g., Sr., Jr., or III.
M
NM108
66
ID 1/2
PAGE 166
Eligibility
NM109
67
Payer Identification
Identification Code
AN 2/80
PAGE 167
271 Segment:
LE Loop Trailer
Loop:
2110D1
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to identify the end of the Dependent Benefit Related Entity Name loop.
Because both the subscribers name loop and this loop begin with NM1 segments, the LS
and LE segments are used to differentiate these two loops. Required if Loop 2120D is
used.
Example: LE*2120~
Data Element Summary
Ref.
Data
Des.
Element
LE01
447
Name
Loop Identifier Code
Attributes
M
AN 1/6
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
This data element must have the value of 2120".
PAGE 168
271 Segment:
Eligibility
Loop:
2110D2-5
Optional
Level:
Summary
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
See X12 Guide. Use this segment to begin the eligibility/benefit information looping
structure. The EB segment is used to convey the specific eligibility or benefit information
for the entity identified.
Example:
EB*1**88**RETAIL HEALTH PLAN NAME ~
EB*1**90**MAIL ORDER HEALTH PLAN NAME ~
EB*1****SPECIALTY HEALTH PLAN NAME ~
MSG*SPECIALTY PHARMACY~
EB*1****LTC HEALTH PLAN NAME ~
MSG*LTC~
Ref.
Data
EB01
1390
ID 1/2
Active Coverage
*Covered
EB03
1365
Non-Covered
ID 1/2
ID 1/3
EB04
1336
88
90
Code identifying the type of insurance policy within a specific insurance program
Use if available.
* See X12 guide for additional qualifiers.
47
LAST PUBLISHED 4/15/11
PAGE 169
EB05
1204
Eligibility
CP
MC
Medicaid
MP
Medicare Primary
OT
AN 1/50
EB07
782
Monetary Amount
R 1/18
Monetary amount
INDUSTRY: Benefit Amount
Use this monetary amount as qualified by EB01.
Use if eligibility or benefit must be qualified by a monetary amount;
e.g., deductible, co-payment.
* Surescripts is utilizing this field for Out of Pocket Accumulator. EB01 set to G.
PAGE 170
271 Segment:
Loop:
2110D2-5
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
20
Purpose:
Semantic Notes:
DTP02 is the date or time or period format that will appear in DTP03.
Comments:
Notes:
When using the DTP segment in the 2110D loop this date applies only to the 2110D
Eligibility or Benefit Information (EB) loop in which it is located.
If a DTP segment with the same DTP01 value is present in the 2100D loop, the date is
overridden for only this 2110D Eligibility or Benefit Information (EB) loop.
Example: DTP*291*RD8*20100101-20101231~
Ref.
Data
Des.
Element
DTP01
374
Name
Attributes
Date/Time Qualifier
ID 3/3
ID 2/3
DTP02
1250
Plan
Code indicating the date format, time format, or date and time format
Use this code to specify the format of the date(s)/time(s) that follow in the next
data element.
D8
RD8
DTP03
1251
AN 1/35
PAGE 171
271 Segment:
Loop:
2110D2-5
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
To specify the validity of the request and indicate follow-up action authorized
Syntax Notes:
Semantic Notes:
AAA01 designates whether the request is valid or invalid. Code "Y" indicates that
the code is valid; code "N" indicates that the code is invalid.
Comments:
Notes:
Use this segment when a request could not be processed at a system or application level
and to indicate what action the originator of the request transaction should take.
Use this segment to indicate problems in processing the transaction specifically related to
specific eligibility/benefit inquiry data contained in the original 270 transaction's dependent
eligibility/benefit inquiry information loop (Loop 2110D).
Example: AAA*N**70*C~
Data Element Summary
Ref.
Data
Des.
Element
AAA01
1073
Name
Attributes
ID 1/1
No
Use this code to indicate that the request or an element
in the request is not valid. The transaction has been
rejected as identified by the code in AAA03.
Yes
Use this code to indicate that the request is valid;
however, the transaction has been rejected as identified
by the code in AAA03.
AAA03
901
ID 2/2
15
33
Input Errors
Use this code only when data is present in this transaction
and no other Reject Reason Code is valid for describing the
error. Detail of the error must be supplied in the MSG
segment of the 2110D loop containing this Reject Reason
Code.
52
53
54
PAGE 172
AAA04
889
Eligibility
55
Inappropriate Product/Service ID
56
Inappropriate Date
57
60
61
62
63
69
70
ID 1/1
Resubmission Allowed
PAGE 173
271 Segment:
Eligibility
Loop:
2110D2-5
Level:
Summary
Usage:
Optional
Mandatory
Max Use:
10
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
MSG02 is not related to the specific characteristics of a printer, but identifies top
of page, advance a line, etc.
If MSG02 is "AA - Advance the specified number of lines before print" then
MSG03 is required.
Notes:
Free form text or description fields are not recommended because they require human
interpretation.
Under no circumstances can an information source use the MSG segment to relay
information that can be sent using codified information in existing data elements. If the
need exists to use the MSG segment, it is highly recommended that the entity needing to
use the MSG segment approach X12N with data maintenance to solve the business need
without the use of the MSG segment.
Benefit Disclaimers are strongly discouraged. See section 1.3.10 Disclaimers Within the
Transaction. Under no circumstances is more than one MSG segment to be used for a
Benefit Disclaimer per individual response.
* This free text is used for Specialty Pharmacy or LTC since there is not a service type
code available to use. The text SPECIALTY PHARMACY will indicate this EB loop is for
Specialty Pharmacy. The text LTC will be used to indicate Long Term Care
Example: MSG*SPECIALTY PHARMACY~
MSG*LTC~
Ref.
Data
Des.
Element
MSG01
933
Name
Free-Form Message Text
Attributes
M
AN 1/264
PAGE 174
271 Segment:
LS Loop Header
Loop:
2110D2-5
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to identify the beginning of the Dependent Benefit Related Entity Name
loop. Because both the subscribers name loop and this loop begin with NM1 segments,
the LS and LE segments are used to differentiate these two loops. Required if Loop
2120D is used
Example: LS*2120~
Ref.
Data
Des.
Element
LS01
447
Name
Loop Identifier Code
Attributes
M
AN 1/6
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
This data element must have the value of 2120".
PAGE 175
271 Segment:
Loop:
2120D2-5
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Notes:
Use this segment to identify an entity by name and/or identification number. This NM1
loop is used to identify a provider (such as the primary care provider), an individual,
another payer, or another information source when applicable to the eligibility response.
Example: NM1*SEP*2*SECONDARY PAYER NAME*****PI*PAYERPARTID~
Example: NM1*13*2*PHARMACY ABC*****SV*NCPDPID~
Ref.
Data
Des.
Element
NM101
98
Name
Attributes
ID 2/3
NM102
1065
PRP
Primary Payer
SEP
Secondary Payer
TTP
Tertiary Payer
ID 1/1
AN 1/60
NM103
1035
Person
Non-Person Entity
Use this name for the organization name if the entity type qualifier is a nonperson entity. Otherwise, this will be the individuals last name.
O
NM104
1036
Name First
AN 1/35
AN 1/25
AN 1/10
NM105
1037
Name Middle
Individual middle name or initial
Use this name only if available and NM102 is "1".
NM107
1039
Name Suffix
PAGE 176
Eligibility
NM108
66
ID 1/2
PI
M
NM109
67
Payer Identification
Identification Code
AN 2/80
PAGE 177
271 Segment:
LE Loop Trailer
Loop:
2110D2-5
Level:
Detail
Usage:
Eligibility
Optional
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to identify the end of the Dependent Benefit Related Entity Name loop.
Because both the subscribers name loop and this loop begin with NM1 segments, the LS
and LE segments are used to differentiate these two loops. Required if Loop 2120D is
used.
Example: LE*2120~
Data Element Summary
Ref.
Data
Des.
Element
LE01
447
Name
Loop Identifier Code
Attributes
M
AN 1/6
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
This data element must have the value of 2120".
PAGE 178
271 Segment:
Eligibility
Loop:
Level:
Summary
Usage:
Mandatory
Max Use:
Purpose:
To indicate the end of the transaction set and provide the count of the transmitted
segments (including the beginning (ST) and ending (SE) segments)
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Use this segment to mark the end of a transaction set and provide control information on
the total number of segments included in the transaction set.
Example: SE*52*0001~
Ref.
Data
Des.
Element
SE01
96
Name
Number of Included Segments
Attributes
M
N0 1/10
SE02
329
AN 4/9
Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
The transaction set control numbers in ST02 and SE02 must be identical. This
unique number also aids in error resolution research. Start with a number, for
example "0001", and increment from there. This number must be unique within
a specific functional group (segments GS through GE) and interchange, but can
repeat in other groups and interchanges.
PAGE 179
271 Segment:
Eligibility
Loop:
Level:
Summary
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
The data interchange control number GE02 in this trailer must be identical to the
same data element in the associated functional group header, GS06.
Comments:
Ref.
Data
Des.
Element
GE01
97
Name
Number of Transaction Sets Included
Attributes
M
N0 1/6
GE02
28
N0 1/9
PAGE 180
271 Segment:
Eligibility
Loop:
Level:
Summary
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Ref.
Data
Des.
Element
IEA01
I16
Name
Number of Included Functional Groups
Attributes
M
N0 1/5
IEA02
I12
N0 9/9
PAGE 181
Eligibility
Introduction:
The purpose of this standard is to define the control structures for the electronic interchange of one or more
encoded business transactions including the EDI (Electronic Data Interchange) encoded transactions of
Accredited Standards Committee X12. This standard provides the interchange envelope of a header and trailer
for the electronic interchange through a data transmission, and it provides a structure to acknowledge the receipt
and processing of this envelope.
Page #
Seg ID
Name
Req
Des
Max
Use
183
185
187
ISA
TA1
IEA
M
O
M
1
1
1
Loop
Repeat
PAGE 182
Segment:
Eligibility
Loop:
Level:
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Data Element Summary
Ref.
Data
Des.
Element
ISA01
I01
Name
Attributes
ID 2/2
ISA02
I02
Authorization Information
AN 10/10
ISA03
I03
ID 2/2
ISA04
I04
Password
Security Information
AN 10/10
This is used for identifying the security information about the interchange sender
or the data in the interchange; the type of information is set by the Security
Information Qualifier (I03)
*Password utilized by the sender to access the receiver system.
M
ISA05
I05
Interchange ID Qualifier
ID 2/2
ISA06
I06
Mutually Defined
Interchange Sender ID
AN 15/15
Identification code published by the sender for other parties to use as the
receiver ID to route data to them; the sender always codes this value in the
sender ID element
*The Sender Participant ID. Participant ID is the Surescripts system Participant
ID.
M
ISA07
I05
Interchange ID Qualifier
ID 2/2
PAGE 183
ZZ
M
ISA08
I07
Eligibility
Mutually Defined
Interchange Receiver ID
AN 15/15
ISA09
I08
Interchange Date
DT 6/6
TM 4/4
ISA10
I09
Interchange Time
Time of the interchange
*Time format HHMM required.
ISA11
I65
Repetition Separator
M
1/1
Type is not applicable; the repetition separator is a delimiter and not a data
element; this field provides the delimiter used to separate repeated occurrences
of a simple data element or a composite data structure; this value must be
different than the data element separator, component element separator, and the
segment terminator
*Surescripts recommends using Hex 1F.
ISA12
I11
ID 5/5
ISA13
I12
N0 9/9
ISA14
I13
Acknowledgment Requested
ID 1/1
ISA15
I14
No Acknowledgment Requested
Usage Indicator
ID 1/1
ISA16
I15
Production Data
Test Data
AN 1/1
Type is not applicable; the component element separator is a delimiter and not
a data element; this field provides the delimiter used to separate component
data elements within a composite data structure; this value must be different
than the data element separator and the segment terminator.
*Surescripts recommends using Hex 1C.
PAGE 184
Segment:
Eligibility
Loop:
Level:
Usage:
Optional
Max Use:
Purpose:
To report the status of processing a received interchange header and trailer or the
non-delivery by a network provider
Syntax Notes:
Semantic Notes:
Comments:
Notes:
Ref.
Data
Des.
Element
TA101
I12
Name
Attributes
N0 9/9
TA102
I08
Interchange Date
DT 6/6
TA103
I09
Interchange Time
TM 4/4
TA104
I17
ID 1/1
This indicates the status of the receipt of the interchange control structure
PAGE 185
Eligibility
Errors Are Noted. This Means the Sender Must Not
Resend This Data.
R
M
TA105
I18
ID 3/3
This numeric code indicates the error found processing the interchange control
structure
000
No error
001
002
003
004
005
006
007
008
009
010
011
012
013
014
015
016
017
018
019
020
021
022
023
024
025
026
027
028
029
030
031
PAGE 186
Segment:
Eligibility
Loop:
Level:
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Ref.
Data
Des.
Element
IEA01
I16
Name
Number of Included Functional Groups
Attributes
M
N0 1/5
IEA02
I12
N0 9/9
PAGE 187
Eligibility
FA
Refer to the 005010X231 guide for purpose and scope of this transaction.
Heading:
Page #
Header
190
193
195
Detail
196
Seg ID
Name
M/C
Max
Use
ISA
GS
ST
M
M
M
1
1
1
AK1
1
>1
C
C
C
M
M
1
>1
1
>1
1
1
M
M
M
1
1
1
197
AK2
198
199
201
203
Trailer
IK3
IK4
IK5
AK9
205
206
207
SE
GE
IEA
Loop
Repeat
PAGE 188
Eligibility
AK2 is used to start the acknowledgment of a transaction set within the received functional group. The AK2
segments shall appear in the same order as the transaction sets in the functional group that has been received
and is being acknowledged.
The data segments of this standard are used to report the results of the syntactical analysis of the functional
groups of transaction sets; they report the extent to which the syntax complies with the standards or proper
subsets of transaction sets and functional groups as expressed in compliant implementation guides. They do not
report on the semantic meaning of the transaction sets (for example, on the ability of the receiver to comply with
the request of the sender).
The CTX Segment shall be used to disambiguate a reported error that is dependent on context.
If any implementation guide errors have been reported in IK3 or IK4, then code I5 shall be reported in the IK5
Segment.
PAGE 189
999 Segment:
Eligibility
Loop:
Level:
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Ref.
Data
Des.
Element
ISA01
I01
Name
Attributes
ID 2/2
ISA02
I02
Authorization Information
AN 10/10
ISA03
I03
ID 2/2
ISA04
I04
Password
Security Information
AN 10/10
This is used for identifying the security information about the interchange sender
or the data in the interchange; the type of information is set by the Security
Information Qualifier (I03)
*Password used by the sender to access the receiver system. Password
assigned by Surescripts.
M
ISA05
I05
Interchange ID Qualifier
ID 2/2
Mutually Defined
PAGE 190
ISA06
I06
Eligibility
Interchange Sender ID
AN 15/15
Identification code published by the sender for other parties to use as the
receiver ID to route data to them; the sender always codes this value in the
sender ID element
*From the Physician System this is the Surescripts system Physician System
Participant ID.
*From Surescripts, this is Surescripts Participant ID.
M
ISA07
I05
Interchange ID Qualifier
ID 2/2
ISA08
I07
Mutually Defined
Interchange Receiver ID
AN 15/15
ISA09
I08
Interchange Date
DT 6/6
TM 4/4
ISA10
I09
Interchange Time
Time of the interchange
*Time format HHDD required.
ISA11
I65
Repetition Separator
M
1/1
Type is not applicable; the repetition separator is a delimiter and not a data
element; this field provides the delimiter used to separate repeated occurrences
of a simple data element or a composite data structure; this value must be
different than the data element separator, component element separator, and the
segment terminator.
*Surescripts recommends using Hex 1F.
ISA12
I11
ID 5/5
ISA13
I12
N0 9/9
ID 1/1
ISA14
I13
Acknowledgment Requested
No Acknowledgment Requested
PAGE 191
ISA15
I14
Eligibility
Usage Indicator
ID 1/1
ISA16
I15
Production Data
Test Data
AN 1/1
Type is not applicable; the component element separator is a delimiter and not
a data element; this field provides the delimiter used to separate component
data elements within a composite data structure; this value must be different
than the data element separator and the segment terminator.
*Surescripts recommends using Hex 1C.
PAGE 192
999 Segment:
Eligibility
Loop:
Level:
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
The data interchange control number GS06 in this header must be identical to
the same data element in the associated functional group trailer, GE02.
A functional group of related transaction sets, within the scope of X12 standards,
consists of a collection of similar transaction sets enclosed by a functional group
header and a functional group trailer.
Ref.
Data
Des.
Element
GS01
479
Name
Attributes
ID 2/2
AN 2/15
GS02
142
GS03
124
AN 2/15
GS04
373
Date
DT 8/8
TM 4/8
GS05
337
Time
GS06
28
N0 1/9
PAGE 193
GS07
455
Eligibility
ID 1/2
Code used in conjunction with Data Element 480 to identify the issuer of the
standard
X
GS08
480
AN 1/12
Code indicating the version, release, subrelease, and industry identifier of the
EDI standard being used, including the GS and GE segments; if code in DE455
in GS segment is X, then in DE 480 positions 1-3 are the version number;
positions 4-6 are the release and subrelease, level of the version; and positions
7-12 are the industry or trade association identifiers (optionally assigned by
user); if code in DE455 in GS segment is T, then other formats are allowed
005010X231
Draft Standards Approved for Publication by ASC X12
Procedures Review Board through October 2003, as
published in this implementation guide.
PAGE 194
999 Segment:
Eligibility
Loop:
Level:
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
The transaction set identifier (ST01) is used by the translation routines of the
interchange partners to select the appropriate transaction set definition (e.g., 810
selects the Invoice Transaction Set).
Comments:
Ref.
Data
Des.
Element
ST01
143
Name
Attributes
ID 3/3
AN 4/9
ST02
329
Implementation Acknowledgment
Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
The transaction set control numbers in ST02 and SE02 must be identical. This
unique number also aids in error resolution research. Start with the number, for
example "0001", and increment from there. This number must be unique within
a specific group and interchange, but can repeat in other groups and
interchanges.
M
ST03
1705
AN 1/35
PAGE 195
999 Segment:
Eligibility
Loop:
Level:
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
AK102 is the functional group control number found in the GS segment in the
functional group being acknowledged.
Comments:
Ref.
Data
Des.
Element
AK101
479
Name
Attributes
ID 2/2
AK102
28
HB
HS
N0 1/9
AK103
480
PAGE 196
Segment:
Loop:
Eligibility
Optional
Level:
Usage:
Optional
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
AK202 is the transaction set control number found in the ST segment in the
transaction set being acknowledged.
Comments:
Ref.
Data
Des.
Element
AK201
143
Name
Attributes
ID 3/3
AK202
329
270
271
AN 4/9
Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
PAGE 197
999 Segment:
Loop:
Eligibility
Optional
Level:
Usage:
Optional
Max Use:
Purpose:
To report errors in a data segment and identify the location of the data segment
Ref.
Data
Des.
Element
IK301
721
Name
Attributes
Segment ID Code
ID 2/3
N0 1/10
IK302
719
The numerical count position of this data segment from the start of the
transaction set: the transaction set header is count position 1
O
IK303
447
AN 1/4
The loop ID number given on the transaction set diagram is the value for this
data element in segments LS and LE
O
IK304
620
ID 1/3
Unrecognized segment ID
Unexpected segment
PAGE 198
999 Segment:
Loop:
Eligibility
Optional
Level:
Usage:
Optional
Max Use:
>1
Purpose:
To report errors in a data element or composite data structure and identify the
location of the data element
Syntax Notes:
Semantic Notes:
In no case shall a value be used for AK404 that would generate a syntax error,
e.g., an invalid character.
Comments:
Data Element Summary
Ref.
Data
Des.
Element
IK401
C030
Name
Position in Segment
Attributes
M
Code indicating the relative position of a simple data element, or the relative
position of a composite data structure combined with the relative position of the
component data element within the composite data structure, in error; the count
starts with 1 for the simple data element or composite data structure
immediately following the segment ID.
M
C03001
722
N0 1/2
This is used to indicate the relative position of a simple data element, or the
relative position of a composite data structure with the relative position of the
component within the composite data structure, in error; in the data segment the
count starts with 1 for the simple data element or composite data structure
immediately following the segment ID.
O
C03002
1528
N0 1/2
To identify the component data element position within the composite that is in
error.
O
IK402
725
N0 1/4
Reference number used to locate the data element in the Data Element
Dictionary.
PAGE 199
IK403
621
Eligibility
ID 1/3
Code indicating the error found after syntax edits of a data element
IK404
724
Invalid Date
Invalid Time
10
AN 1/99
PAGE 200
999 Segment:
Loop:
Eligibility
Optional
Level:
Usage:
Mandatory
Max Use:
Purpose:
Ref.
Data
Des.
Element
IK501
717
Name
Attributes
ID 1/1
Code indicating accept or reject condition based on the syntax editing of the
transaction set
A
Accepted
Rejected
* Surescripts recommends R.
IK502
618
ID 1/3
Code indicating error found based on the syntax editing of a transaction set
10
11
12
13
PAGE 201
IK503
618
Eligibility
15
16
17
19
20
21
22
23
24
25
26
27
ID 1/3
Code indicating error found based on the syntax editing of a transaction set
Same Codes as IK502
O
IK504
718
ID 1/3
Code indicating error found based on the syntax editing of a transaction set
Same Codes as IK502
O
IK505
718
ID 1/3
Code indicating error found based on the syntax editing of a transaction set
Same Codes as IK502
O
IK506
718
ID 1/3
Code indicating error found based on the syntax editing of a transaction set
Same Codes as IK502
PAGE 202
999 Segment:
Eligibility
Loop:
Level:
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
If AK901 contains the value "A" or "E", then the transmitted functional group is
accepted.
Ref.
Data
Des.
Element
AK901
715
Name
Attributes
ID 1/1
Code indicating accept or reject condition based on the syntax editing of the
functional group
A
Accepted
Rejected
*Surescripts recommends use of R.
AK902
97
N0 1/6
AK903
123
N0 1/6
N0 1/6
ID 1/3
AK904
AK905
716
Code indicating error found based on the syntax editing of the functional group
header and/or trailer
1
PAGE 203
AK906
716
Eligibility
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
ID 1/3
Code indicating error found based on the syntax editing of the functional group
header and/or trailer (Same codes as AK905)
O
AK907
716
ID 1/3
Code indicating error found based on the syntax editing of the functional group
header and/or trailer (Same codes as AK905)
O
AK908
716
ID 1/3
Code indicating error found based on the syntax editing of the functional group
header and/or trailer (Same codes as AK905)
O
AK909
716
ID 1/3
Code indicating error found based on the syntax editing of the functional group
header and/or trailer (Same codes as AK905)
LAST PUBLISHED 4/15/11
PAGE 204
999 Segment:
Eligibility
Loop:
Level:
Usage:
Mandatory
Max Use:
Purpose:
To indicate the end of the transaction set and provide the count of the transmitted
segments (including the beginning (ST) and ending (SE) segments)
Syntax Notes:
Semantic Notes:
Comments:
Ref.
Data
Des.
Element
SE01
96
Name
Number of Included Segments
Attributes
M
N0 1/10
SE02
329
AN 4/9
Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
The transaction set control numbers in ST02 and SE02 must be identical. This
unique number also aids in error resolution research. Start with a number, for
example "0001", and increment from there. This number must be unique within
a specific group and interchange, but can repeat in other groups and
interchanges.
PAGE 205
999 Segment:
Eligibility
Loop:
Level:
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
The data interchange control number GE02 in this trailer must be identical to the
same data element in the associated functional group header, GS06.
Comments:
Notes:
Ref.
Data
Des.
Element
GE01
97
Name
Number of Transaction Sets Included
Attributes
M
N0 1/6
GE02
28
N0 1/9
PAGE 206
999 Segment:
Eligibility
Loop:
Level:
Usage:
Mandatory
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Ref.
Data
Des.
Element
IEA01
I16
Name
Number of Included Functional Groups
Attributes
M
N0 1/5
IEA02
I12
N0 9/9
PAGE 207
Eligibility
Note: In the examples, line breaks are used at the end of the segments for display
purposes live transactions should not contain line breaks.
PAGE 208
Eligibility
Segment
Value
Note
ISA
ISA
PWPHY12345
POCID
ISA
BHT
S00000000000001
3920394930203
HL1:NM1
SURESCRIPTS
LLC
TIM JONSON
3334444
Tina James
30
HL2:NM1
HL2:NM1
HL3:NM1
EQ
Dr.s Name.
Dr Jonson DEA number 3334444.
Tina James is the patient.
Health Plan Benefit Coverage
PAGE 209
Eligibility
Value
Note
ISA
ISA
ISA
BHT
PW12345PBM
S00000000000001
PBM123
3920394930203
HL1:NM1
HL2:NM1
HL2:NM1
HL2:REF
HL3:NM1
EQ
PBM COMPANY
TIM JONSON
3334444
POCID
Tina James: PBM11356
30
PAGE 210
Eligibility
PAGE 211
Eligibility
Segment
Value
Note
ISA
PWPBM12345
ISA
PBM123
ISA
S00000000000001
BHT
3920394930203
HL1:NM1
PBM COMPANY
HL2:NM1
HL2:REF
POCID
HL3:NM1
HL3:REF
HJ
CardholderID
HL3:REF
49
00 Person Code.
EB 1:30
HL3:REF
18
Plan Number
HL3:REF
6P
HL3:REF
ALS
Alternative List ID
HL3:REF
CLI
Coverage List ID
HL3:REF
FO
Formulary ID
HL3:REF
IG
Copay ID
HL3:REF
N6
EB1:88
EB1:90
Value
Note
ISA
PW12345PHY
ISA
S00000000000001
ISA
POCID
PAGE 212
Eligibility
PAGE 213
Eligibility
PAGE 214
Eligibility
GE*1*1~
IEA*1*000000001~
PAGE 215
Eligibility
Segment
Value
Note
ISA
PWPBM12345
ISA
PBM123
ISA
S00000000000001
BHT
3920394930203
HL1:NM1
PBM COMPANY
HL2:NM1
HL2:REF
POCID
HL3:NM1
HL3:REF
HJ
CardholderID
HL3:REF
49
00 Person Code.
EB 1:30
HL3:REF
18
Plan Number
HL3:REF
6P
HL3:REF
ALS
Alternative List ID
HL3:REF
CLI
Coverage List ID
HL3:REF
FO
Formulary ID
HL3:REF
IG
Copay ID
HL3:REF
N6
EB1:88
EB1:90
EB1
MSG
SPECIALTY
PHARMACY
EB1
MSG
LTC
PAGE 216
Eligibility
PAGE 217
Eligibility
PAGE 218
Eligibility
4.14 TRANSLATION
Some of the fields can be translated between versions while others will result in a
translation error. Following are a list of fields that will be translated.
1. AAA Error codes
Loop 2100C
4010
5010
64 Invalid/Missing Patient ID
65 Invalid/Missing Patient Name
72 Invalid/Missing Subscriber/Insured ID
73 Invalid/Missing Subscriber/Insured
Name
74 Invalid/Missing Subscriber/Insured
Gender Code
75 Subscriber/Insured Not Found
76 Duplicate Subscriber/Insured ID
Number
Translation Error
2. Date qualifiers 472 Date of Service, 307 Eligibility, and 435 Admission will be
translated in 5010 to 291 Plan Date. When translated from 5010 to 4010 291 will
be translated to 472.
3. Reference Numbers will be moved to the appropriate loop and qualifiers changed
if necessary. REF segments in 4010 Loop 2100C/D will be moved in 5010 to
Loop 2110C/D in EB loop 30. When translating from 5010 to 4010 after the REF
segments are moved, the EB30 loop will be removed.
4. Service Codes 6 active (4010) and I not covered (5010) will be translated
between versions.
5. If no name is provided on Loop 2100A and 2100B in 4010, then UNKNOWN will
be mapped to 5010.
6. If no city name is provided in N401, the UNKNOWN will be mapped to 5010
7. If the dependant name segment in 4010 contains any ID code and qualifier
(NM108 and NM109, it will be rejected when translating to 5010 because 5010
does not support those elements at that level.
8. If the INS segment student status and handicap status are used it will be rejected
when translating to 5010.
9. When translating from 5010 to 4010, we will reject if field is too long. Fields that
have had the length increased in 5010 are listed in number 5 of the page above.
PAGE 219
SECTION 5
Depending on the connectivity between participants, the error processing may differ slightly. This section lays out the error
processing for the supported connection types. It also contains the error processing that happens within the 270/271 transaction that
will be consistent regardless of connectivity type.
The system (Surescripts) will store the request until the receiver responds to the message or until the specified time has elapsed. If
the timeout elapses before the message is processed, an error message will be returned to the sender as the reply (explained
below). If the sender has timed out, the message is discarded.
The Eligibility (270/271) transaction is a transaction where Surescripts is a defined participant in the process and adds processing
value in the middle. For that reason, additional error processing needs to be handled. The following section outlines the life of the
Eligibility message with the expected responses to different flows of events. It is broken down into the following stages:
Surescripts receives the 270 from the requesting party.
Surescripts processes the 270, identifying the coverage(s).
Surescripts passes the 270 on to the defined source. (If multiple coverages are found, multiple 270s are sent.)
The source processes the request(s) and returns a 271 response.
Surescripts combines the response(s) into one envelope.
Surescripts passes the response back to the original requester.
PAGE 220
5.1
SURESCRIPTS RECEIVES THE 270 FROM THE REQUESTING PARTY (TECH VENDOR)
Event
Id
Location
Event
Surescripts
Response
Error Description
Requestor Follow-Up
1.0
Connectivity Error
None
None
1.1
Translation
NAK
1.2
Translation
TA1
1.3
Translation
999
5.2
Event
Id
Location
Event
Surescripts
Response
Error Description
Requestor Follow-up
2.0
Source Segment
Loop ID 2000A
271
2.1
Source Segment
Loop ID 2000A
271
2.2
Source Segment
Loop ID 2000A
271
2.3
Source Segment
Loop ID 2000A
271
Loop ID 2000A
AAA Error 42 Unable to Respond a
current time
Loop ID 2000A
AAA Error 42 Unable to Respond a
current time
Loop ID 2000A
AAA Error 79
Invalid participant identification
Loop ID 2000A
AAA Error 41
Authorization/Access Restrictions
P Please resubmit
PAGE 221
Event
Id
Location
Event
Surescripts
Response
Error Description
Requestor Follow-up
2.4
Source Name
Segment
Loop ID 2100A
271
2.5
Subscriber Name
Segment Loop ID
2100C
Subscriber Name
Segment Loop ID
2100C
Subscriber
Request Validation
Segment Loop ID
2110C
271
271
271
271
271
271
2.5a
2.5b
2.6
2.6a
2.7
Dependent Name
Segment Loop ID
2100D
Dependent Name
Segment Loop ID
2100D
Dependent
Request Validation
Segment Loop ID
2110D
PAGE 222
5.3
Event
Id
Location
Event
PBM
Response
PBM Error
Description
Surescripts
Follow up
Requestor Follow Up
3.0
Surescripts to
PBM Connector
None
None
Investigate and
create AAA
error for
requestor
P Please Resubmit
Original Transaction
3.1
PBM Internal
NAK
Text Error
Message
Investigate and
create AAA
error for
requestor
Source Segment
Loop 2100A
AAA Error 80
No Response received Transaction Terminated
New in 5010
Source Segment
Loop 2000A
AAA Error 42
Unable to respond at
current time
5.4
S Do not resubmit;
Inquiry initiated to a
third party.
Event
Id
Location
Event
PBM
Response
PBM Error
Description
Surescripts
Follow up
Requestor Follow Up
4.0
Translation Initiation
TA1
Investigate and
create AAA
error for
requestor
Source Segment
Loop 2000A
AAA Error 42
Unable to respond at
current time
S Do not resubmit;
Inquiry initiated to a
third party.
4.1
Translation Initiation
999
Refer to X12
004010 Data
Element
Dictionary for
acceptable
codes
Refer to the 999
spec to
determine AK
level and
appropriate
error
Investigate and
create AAA
error for
requestor
Source Segment
Loop 2000A
AAA Error 42
Unable to respond at
current time
S Do not resubmit;
Inquiry initiated to a
third party.
PAGE 223
5.5
Even
t Id
Location
Event
PBM
Response
PBM Error
Description
PBM Follow
up
Surescripts
Follow up
Requestor
Follow Up
5.0
Source Segment
Loop ID 2100A
(Note:
Information
Source is the
PBM info that was
supplied by
Surescripts)
271
Source Segment
Loop 2100A
AAA Error 42
Unable to respond
at current time
None
Source Segment
Loop 2100A
AAA Error 42
Unable to respond at
current time
P Please
Resubmit
Original
Transaction
5.1
Source Segment
Loop ID 2100A
(Note:
Information
Source is the
PBM info that was
supplied by
Surescripts)
Source Name
Segment Loop ID
2100A (Note:
Information
Source is the
PBM info that was
supplied by
Surescripts)
271
Source Segment
Loop 2100A
AAA Error 79
Invalid Participant
Identification
Investigate
and contact
Surescripts
production
support if
additional
information
or
clarification
is needed.
Investigate
and contact
Surescripts
production
support
Investigate and
translate to
AAA system
error for
requestor
Source Segment
Loop 2100A
AAA Error 79
Invalid Participant
Identification
S Do not
resubmit;
Inquiry
initiated to a
third party
271
Source Segment
Loop 2100A
AAA Error 79
Invalid Participant
Identification
Investigate
and contact
Surescripts
production
support
Investigate and
translate to
AAA system
error for
requestor
Source Segment
Loop 2100A
AAA Error 79
Invalid Participant
Identification
S Do not
resubmit;
Inquiry
initiated to a
third party
5.2
PAGE 224
Even
t Id
Location
Event
PBM
Response
PBM Error
Description
PBM Follow
up
Surescripts
Follow up
Requestor
Follow Up
5.3
Receiver Segment
Loop ID 2100B
(This loop
contains the
physician info and
the Physician
System info)
271
Receiver Segment
Loop ID 2100B
AAA Error 15
Required
application data
missing
None
None
Receiver Segment
Loop ID 2100B
AAA Error 15
Required application
data missing
5.4
Receiver Segment
Loop ID 2100B
(This loop
contains the
physician info and
the Physician
System info)
271
Receiver Segment
Loop ID 2100B
AAA Error 41
Authorization/
Access
restrictions
None
None
Receiver Segment
Loop ID 2100B
AAA Error 41
Authorization/
Access restrictions
5.5
Receiver Name
Segment Loop ID
2100B
271
Receiver Name
Segment Loop ID
2100B
AAA Error 43
Invalid/Missing
Provider
Identification
None
None
Receiver Name
Segment Loop ID
2100B
Physician Loop
AAA Error 43
Invalid/Missing
Provider
Identification
C Please
correct and
resubmit
Surescripts
recommend
s this value,
however a
PBM/Payor
might send
a different
value
N
Resubmissi
on not
allowed
Surescripts
recommend
s this value,
however a
PBM/Payor
might send
a different
value
C Correct and
Resubmit
Surescripts
recommend
s this value,
however a
PBM/Payor
might send
a different
value
PAGE 225
Even
t Id
Location
Event
PBM
Response
PBM Error
Description
PBM Follow
up
Surescripts
Follow up
Requestor
Follow Up
5.8
Subscriber Name
Loop ID 2100C
271
None
None
S Do not
resubmit;
Inquiry
initiated to a
third party
5.11
Dependant Name
Loop ID 2100D
Patient found at
Surescripts, but not in
the PBMs system
(could be caused by a
difference between
Surescripts and the
PBMs patient
databases or caused by
the patient demographic
mismatch between
requestor and PBM).
Patient found at
Surescripts, but not in
the PBMs system
(could be caused by a
difference between
Surescripts and the
PBMs patient
databases or caused by
the patient demographic
mismatch between
requestor and PBM).
271
Dependant Name
Segment Loop ID
2100D AAA
Error 67 Patient
not found
None
None
Dependant Name
Segment Loop ID
2100D AAA Error
67 Patient not
found
S Do not
resubmit;
Inquiry
initiated to a
third party
PAGE 226
5.6
Event
Id
Location
Event
Surescripts
Response
Surescripts
Error
Description
PBM Follow up
Surescripts
Follow up
Requestor
Follow Up
6.0
Translation of 271
from PBM
TA1
Investigate and
contact
Surescripts
production
support
Investigate
and translate
to AAA system
error for
requestor
Source Segment
Loop 2100A
AAA Error 42
Unable to respond at
current time
S - Do not
resubmit;
Inquiry
initiated to a
third party
6.1
Translation of 271
from PBM
999
Investigate and
contact
Surescripts
production
support
Investigate
and translate
to AAA system
error for
requestor
Source Segment
Loop 2100A
AAA Error 42
Unable to respond at
current time
S - Do not
resubmit;
Inquiry
initiated to a
third party
6.2
Refer to
NCPDP Data
Element
Dictionary for
acceptable
codes
Refer to the 999
spec to
determine AK
level and
appropriate
error
Cannot
Translate to
Version
Investigate and
contact
Surescripts
production
support
Investigate
and translate
to AAA system
error for
requestor
Loop 2000A
AAA Error 42
Unable to respond at
current time
N
Resubmission
Not Allowed
5.7
Log Error
Description
Source Segment
Loop 2000A
AAA Error 42
Generic error message for all errors that occurred that were
not caused by the Physician System.
PAGE 227
5.8
Error
Description
Receiver Segment
Loop ID- 2100B
AAA Error 15
Source Segment
Loop ID- 2000A
AAA Error 41
Subscriber Name
Segment Loop ID 2100C
AAA Error 75
Receiver Segment
Loop ID- 2100B
AAA Error 41
Receiver Segment
Loop ID- 2100B
AAA Error 43
Subscriber Name
Segment Loop ID 2100C
AAA Error 75
Dependant Name
Segment Loop ID 2100D
AAA Error 67
Error
Connectivity Type
Source Segment
Loop 2000A
AAA Error 42
PAGE 228
PAGE 229
ID Load
ID LOAD
SECTION 6
6.1
INTRODUCTION
PBMs use the ID Load transaction to provide Surescripts with their member roster to
populate the Surescripts Master Patient Index (MPI). Surescripts uses these files
from the PBMs to establish uniqueness for individuals across PBMs. Surescripts
search process uses demographics to identify a patient and then uses the PBMs
unique member ID to communicate with the PBMs.
6.2
6.3
FORMAT TO BE USED
Surescripts has implemented a custom specification that contains demographic and
PBM specific information. There are two formats supported; one is a flat fixed width
file. The other is a delimited filed format. Use the same character set as referenced
in Section 4.4.3.2 except for the ^ character decimal 94 which cannot be used in
the ID Load Process.
6.4
Header Info
Field
Description
Type
Start
End
Required
Section Identifier
N 1/1
Yes
Participant ID
ID as assigned by
Surescripts identifying the
PBM
AN 3/30
31
Yes
PAGE 230
ID Load
Field
Description
Type
Start
End
Required
Participant Password
AN 10/10
32
41
Yes
Transaction Number
AN 1/10
42
51
Yes
Transaction Date
DT 8/8
52
59
Yes
Transaction Time
TM 8/8
60
67
Yes
Usage Indicator
ID 1/1
68
68
Yes
Version Number
Version of Member
Directory File Format (1.0)
AN 1/5
69
73
No
Filler
AN 723
74
796
Yes
Detail Info
Field
Description
Type
Start
End
Required
Section Identifier
N 1/1
Yes
Record Sequence
Number
AN 1/10
11
Yes
PBM Unique
Member ID
Unique ID as
identified by the PBM
for the member
AN 1/60
12
71
Yes
Unique identification
number for this
member.
Unique ID as
identified by the PBM
for the subscriber of
the member
AN 1/60
72
131
No
AN 1/30
132
161
No
Health Plan
Subscriber Number
AN 1/30
162
191
No
Policy Number
AN 1/30
192
221
No
Member Expiration
Date
DT 8/8
222
229
No
Notes
ID Load
Field
Description
Type
Start
End
Required
Last Name
AN 1/35
230
264
Yes
First Name
AN 1/25
265
289
Yes
Middle Name
AN 1/25
290
314
No
Prefix
Member Prefix
AN 1/10
315
324
No
Suffix
Member Suffix
AN 1/10
325
334
No
Social Security
Number
Member SSN - No
dashes
N 9/9
335
343
No
Address Line 1
AN 1/55
344
398
No
Address Line 2
AN 1/55
399
453
No
City Name
AN 2/30
454
483
No
State or Province
Code
AN 2/2
484
485
No
Postal Code
AN 3/15
486
500
No
Country Code
Member Country
Code
AN 2/3
501
503
No
Comm Number 1
Type
AN 2/2
504
505
No
Communication
Number 1
1st Communication
Number
AN 1/80
506
585
No
Communication
Number 2 Type
2nd Communication
Number Type
AN 2/2
586
587
No
Communication
Number 2
2nd Communication
Number
AN 1/80
588
667
No
Notes
three.
EM = Email
EX = Telephone
Extension
FX = Facsimile
HP = Home Phone
TE = Telephone
WP = Work Phone
EM = Email
EX = Telephone
Extension
FX = Facsimile
HP = Home Phone
TE = Telephone
WP = Work Phone
PAGE 232
ID Load
Field
Description
Type
Start
End
Required
Notes
Communication
Number 3 Type
3rd Communication
Number Type
AN 2/2
668
669
No
EM = Email
EX = Telephone
Extension
FX = Facsimile
HP = Home Phone
TE = Telephone
WP = Work Phone
Communication
Number 3
3rd Communication
Number
AN 1/80
670
749
No
Date of Birth
Member DOB
(CCYYMMDD)
DT 8/8
750
757
No
Gender
Member Gender
(M,F,U, Blank)
AN 1/1
758
758
No
Employer Name
Employer Name
AN 1/35
759
793
No
Transaction Type
Type of Action
needed
AN 3/3
794
796
Yes
001 - Change
021 - Addition
024 - Cancellation or
Termination
025 - Reinstatement
030 - Audit or
Compare
Trailer Info
Field
Description
Type
Start
End
Required
Section Identifier
N 1/1
Yes
Total Records
N 1/10
11
Yes
Filler
AN 785
12
796
Yes
6.5
Header Info
Field
Description
Type
Start
End
Section Identifier
N 1/1
Participant ID
ID as assigned by Surescripts
identifying the PBM
AN 3/30
31
Sender ID
ID of Surescripts
An 3/30
32
61
Transaction Number
AN 1/10
62
71
Incoming Transaction
Date
DT 8/8
72
79
Incoming Transaction
Time
TM 8/8
80
87
Transaction Date
DT 8/8
88
95
Notes
Participant ID of
Original File
Sender
PAGE 233
ID Load
Field
Description
Type
Start
End
Transaction Time
TM 8/8
96
103
Transaction
Response
AN 2/2
104
105
Records Loaded
N 1/10
106
115
Records Failed
N 1/10
116
125
Notes
Detail Info
Field
Description
Type
Start
End
Section Identifier
N 1/1
Record Sequence
Number
AN 1/10
11
AN 1/60
12
71
Error Code
AN 3/3
72
74
Filler
AN 51
75
125
Field
Description
Type
Start
End
Section Identifier
N 1/1
Filler
AN 124
125
Notes
Trailer Info
Notes
PAGE 234
6.6
ID Load
Each field is delimited by the pipe character (|). Each line is separated by a new line (Hex 0A) character. The
tilde character (~) is used as a repetition character currently only supported in the postal code field.
Header Info
Field #
Field Name
Type
Required
Comments
Example
Record Type
AN 3/3
Yes
Identifies record
type
Value = HDR
Version/Release
Number
AN 1/2
Yes
Version Number
of this
specification
2.1
Sender ID
AN 3/30
Yes
ID as assigned
by Surescripts
identifying
Participant
sending the file.
P11111111111111
Sender Participant
Password
AN 10/10
Yes
Password for
this Participant
identified in field
3 (Sender ID).
ABCDE12345
Receiver ID
AN 1/30
Yes
ID identifying
the receiver of
the file.
RXHUB
Source Name
AN 1/35
Not Used
Future use
Transmission
Control Number
AN 1/10
Yes
Unique identifier
defined by the
sender
0000001000
Transmission
Date
DT 8/8
Yes
Date
transaction was
created (D8 CCYYMMDD)
20060701
Transmission
Time
TM 8/8
Yes
Time
transaction was
created
(HHMMSSDD)
12200101
10
Transmission File
Type
AN 1/3
Yes
Identifier telling
the type of
transaction
MPI=ID load
MPI
11
Transmission
Action
AN 1/1
No
U=Update
F=Full file
If blank, default
to U=Update
12
Extract Date
DT 8/8
Yes
20060630
13
File Type
AN 1/1
Yes
Test or
Production T=Test,
P=Production
PAGE 235
ID Load
Detail Info
Field #
Field Name
Type
Required
Comments
Record Type
AN 3/3
Yes
Identifies record
type
Record Sequence
Number
AN 1/10
Yes
PBM Unique
Member ID
AN 1/60
Yes
Unique ID as
identified by the
PBM for the
member
PBM Unique ID
for Subscriber
AN 1/60
No
Unique ID as
identified by the
PBM for the
subscriber of the
member
Health Plan
Member Number
AN 1/30
No
Health Plan
Unique Member
identification
number
Number on the
Health Plan card
identifying the
patient (Either a
subscriber or a
dependant)
Health Plan
Subscriber
Number
AN 1/30
No
Health Plan
Unique
Subscriber
identification
number - Number
on the Health
Plan card
identifying the
subscriber
Policy Number
AN 1/30
No
Member
Expiration Date
DT 8/8
No
Last Name
AN 1/35
Yes
10
First Name
AN 1/25
Yes
11
Middle Name
AN 1/25
No
Middle Name of
the Member
12
Prefix
AN 1/10
No
Member Prefix
13
Suffix
AN 1/10
No
Member Suffix
Example
Value = MEM
PAGE 236
Field #
ID Load
Field Name
Type
Required
Comments
14
Social Security
Number
N 9/9
No
15
Address Line 1
AN 1/55
No
16
Address Line 2
AN 1/55
No
Second Line of
the Address (No
C/O type info)
17
City Name
AN 2/30
No
Member City
Name
18
State or Province
Code
AN 2/2
No
Member State
Code
19
Postal Code
AN 3/15
Can repeat
up to five
times.
No
20
Country Code
AN 2/3
No
Member Country
Code
21
Comm Number 1
Type
AN 2/2
No
1st Comm.
Number Type
Example
55123~55102
EM = Email
EX = Telephone
Extension
FX = Facsimile
HP = Home Phone
TE = Telephone
WP = Work Phone
22
Communication
Number 1
AN 1/80
No
1st
Communication
Number
23
Communication
Number 2 Type
AN 2/2
No
2nd
Communication
Number Type
EM = Email
EX = Telephone
Extension
FX = Facsimile
HP = Home Phone
TE = Telephone
WP = Work Phone
24
Communication
Number 2
AN 1/80
No
2nd
Communication
Number
PAGE 237
Field #
25
ID Load
Field Name
Type
Required
Comments
Example
Communication
Number 3 Type
AN 2/2
No
3rd
Communication
Number Type
EM = Email
EX = Telephone
Extension
FX = Facsimile
HP = Home Phone
TE = Telephone
WP = Work Phone
26
Communication
Number 3
AN 1/80
No
3rd
Communication
Number
27
Date of Birth
DT 8/8
No
Member DOB
(CCYYMMDD)
28
Gender
AN 1/1
No
Member Gender
(M,F,U, blank)
29
Employer Name
AN 1/35
No
Employer Name
30
Transaction Type
AN 3/3
Yes
Type of Action
needed
001 - Change
021 - Addition
024 - Cancellation or
Termination
025 - Reinstatement
030 - Audit or
Compare
Field Name
Type
Required
Comments
Example
Record Type
AN 3/3
Yes
Identifies record
type
Value = TRL
2 Total Records
N 1/10
Yes
Total Records
Processed
Trailer Info
Field #
6.7
Header
Field
Description
Type
Record Type
AN 3/3
Yes
Value = SHD
Version/Release
Number
AN 1/2
Yes
2.0
Sender ID
ID as assigned by Surescripts
identifying Surescripts
AN 3/30
Yes
Recipient ID
AN 3/30
Yes
Required
Notes
PAGE 238
ID Load
Field
Description
Type
Required
Notes
Recipient Participant
Password
Password assigned by
Surescripts for accessing the
payer/PBM system.
AN 10/10
Yes
Transaction Control
Number
AN 1/10
Yes
Transaction Date
DT 8/8
Yes
Transaction Time
TM 8/8
Yes
HHMMSSDD
AN 1/3
Yes
MPR
AN 1/10
Yes
Transaction DateOriginating
DT 8/8
Yes
CCYYMMDD
Transaction TimeOriginating
TM 8/8
Yes
HHMMSSDD
File Type
AN 1/1
Yes
T=Test
P=Production
Load Status
AN 2/2
Yes
See chart
CCYYMMDD
Detail Info
Field
Description
Type
Required
Notes
Record Type
N 1/1
Value=SDT
Record Sequence
Number
AN 1/10
11
AN 1/60
71
Error Code
AN 3/3
74
Field
Description
Type
Required
Notes
Record Type
AN 3/3
Yes
Value = STR
N 1/10
Yes
See table
Trailer Info
6.8
Description
01
02
03
04
05
PAGE 239
06
07
08
09
10
11
12
13
14
15
17
ID Load
Description
E01
E02
E03
E04
E05
E07
E09
E10
W04
W05
W06
W07
W08
A00
Audit Compare, record not loaded. This is used when the file header
transaction type is set to 030 Audit or Compare.
PAGE 240
ID Load
PAGE 241
SECTION 7
7.1
INTRODUCTION
During the prescribing process, technology vendor systems typically use the
information retrieved through the Formulary and Benefit Data Load service to inform
prescribers of the following:
PAGE 242
7.2
ID
Alt
ern
ati
v
es
ID
Alternatives List
ve
Co
ge
ra
ID
D
ay I
Cop
Classif
ication
Formulary ID
Keys:
Product Name - Health
Plan
Alternatives ID
Source drug identifier(s)
Alternative drug
identifier(s)
Preference Level
Classification List
Keys:
Product Name - Health
Plan
Classification ID
Drug identifier(s)
Coverage List
multiple sub-types
Copay List
sub-types:
Summary-Level
Drug-Specific
Keys:
Product Name - Health
Plan
Copay ID
Pharmacy Type
Drug-Specific Copay List
only:
Drug identifier(s)
Keys:
Product Name - Health
Plan
Coverage ID
Drug identifier(s)
Additional keys based on
sub-type
Text Message
Product Exclusion
Prior Authorization
Medical Necessity
Coverage
Sub-Types
Step Medication
Quantity Limit
Age Limit
Gender Limit
Resource Link
Note: "Drug ID" represents several supported drug identifiers
sub-types:
Summary-Level
Drug-Specific
PAGE 243
7.3
7.3.1
FORMULARY STATUS
Pharmacy benefit payers use the drug formulary as a way to promote high-quality
medical care that is affordable for patients. A drug formulary is a list of prescription
drugs; each one assigned a formulary status, which is a rating of that drugs
effectiveness and value. Payers periodically publish revisions to their drug
formularies, in order to represent the current clinical judgment of the payer and its
affiliated care providers.
Payers determine a drugs formulary status by considering its efficacy and value
compared to other drugs in the same therapeutic class (a grouping of medications
known to be effective for a particular diagnosis). Those drugs with a higher rating
obtain a higher formulary status (e.g. on-formulary or preferred).
If a therapeutic class contains multiple drugs, those with higher formulary statuses
are referred to as preferred alternatives to those with lower ratings. Drugs
deemed to have lesser effectiveness and/or value are called off-formulary. Payers
encourage doctors to prescribe drugs with on-formulary or preferred formulary
status in order to lower benefit costs and reduce the patients out-of-pocket
expense.
Formulary status is defined by using a simple, low-to-high scale. Drugs with a lower
formulary status are considered less preferable by the payer; those with a ghigher
status are more preferable.
Formulary Status
1 = Non-Formulary
2 = On Formulary
3 99 = On FormularyPreferred (higher number means more
preferred)
Payers can flag drugs that the benefit simply does not cover at any level. These
drugs are referred to as non-reimbursable, meaning that the patient bears full
responsibility for their cost.
0 = Non-Reimbursable
If the payer does not know a status for a drug but it is listed within the file, the
receiver should interpret this as an unknown status for this drug and not use the
formulary status defaults in the header.
U = Unknown Status
If a drug is not listed in the file, a Formulary Status can be specified by using the
Non-Listed Formulary Status fields in the header (e.g. Non-listed Prescription
PAGE 244
Brand Formulary Status, Non-Listed Prescription Generic Formulary Status, NonListed Brand Over-The-Counter Formulary Status, etc.).
It is possible for drugs within the same therapeutic class to have the same
formulary status. For example, there may be several non-reimbursable drugs as
well as five formulary drugs; three of which are a preferred level 3 and two
designated as a preferred level 4. Note that the most preferred products in this
example are the two level 4 products.
7.3.2
PAYER-SPECIFIED ALTERNATIVES
As discussed above, drugs with a higher formulary status than others of the same
therapeutic class are considered to be preferred alternatives to those with lower
ratings. Therefore, technology vendor systems can identify preferred alternatives by
comparing the status of drugs within a therapeutic class.
In addition, payers can explicitly state alternatives for specific drugs. These payerspecified alternatives are communicated in Alternatives lists, which contain the
following information:
7.3.3
COVERAGE INFORMATION
Coverage information qualifies the conditions under which the patients pharmacy
benefit covers a medication. For instance, a drug may be covered only for patients
under a certain age, or of a certain gender. Other drugs may be covered up to a
certain quantity. Payers can communicate the following coverage factors to
technology vendor systems using the file load:
The file load also enables payers to specify a single coverage-related text message
for each drug, and links to additional information available on the payers web site.
PAGE 245
7.3.4
COPAY INFORMATION
Copay information describes the cost to the patient the extent to which the
patient is responsible for the cost of a prescription. The specification supports
multiple ways to state this cost, including flat dollar amounts, percentages, and tier
levels. Payers may use one, or a combination of these options.
For instance, a flat $10 patient copay may apply to one drug, and a 15% copay
may apply to another. One payer may state copay exclusively in terms of copay
tiers, where lower tiers mean a lower patient copay.
Payers can communicate the following copay terms to technology vendor systems
using the file load:
Summary-level copay. Often, a class of medications will receive the same copay
(generics, for example). Payers can state a summary-level copay rule, based on a
drugs Formulary Status and its type (Branded or Generic). Any drug with the
characteristics stated in the summary-level rule receives the copay defined in the
rule.
Drug-specific copay. Exceptions to these summary-level rules will also frequently
exist. To accommodate these exceptions, Payers can state drug-level copays.
These copays apply to specific drugs, as identified with a representative 11-digit
NDC ID
7.3.5
Class ID
Class Name
PAGE 246
7.3.6
Subclass ID
Subclass Name
CROSS-REFERENCE INFORMATION
The Cross-Reference list enables payers to tie the different types of formulary and
benefits information to a particular benefit plan or group. A technology vendor uses
this list as a sort of index to locate the various lists that combine to form a
membership groups full benefits picture.
For instance, Membership Group As benefit is composed of the following pieces:
Formulary 101
Alternatives list 20
Coverage list A
Copay list A
Drug Classification 1
Using the Cross-Reference list, payers can associate the following data keys to a
membership group:
Formulary ID
Alternatives ID
Coverage List ID
Copay List ID
Classification ID
7.4
PAGE 247
7.5
7.5.1
7.5.2
PAGE 248
4. If no drug-specific copay is found for this medication, look up the copay based on
the drugs characteristics.
a. Determine the medications formulary status: See step 3 in the previous
example, Flow One: Presenting Formulary and Coverage Information.
b. If the previous step results in a formulary status of Not Reimbursable, the
patient has full responsibility for its cost.
o Skip the remaining step. (Do NOT display copay information.
c. Search the Benefit Copay List / Copay Information Detail - Summary Level
for the record that matches this medications characteristics (below) and
present the copay terms for each type of pharmacy specified by the payer:
o Formulary Status
o Product Type (single source brand, branded generic, generic,
over-the-counter, compound, supply)
7.5.3
PAGE 249
7.6
Formulary Retrievers
Formulary Retrievers download the formulary information from the Surescripts
WebDAV server and integrate it into their point-of-care application. With this
information, prescribers can check a prescription drug against a patients formulary,
view coverage/copay limitations, and consider alternative medications.
Surescripts
Surescripts role in the Formulary and Benefit Data Load process is to:
7.7
PAGE 250
1. The Formulary Publisher develops their formulary and benefit file layout
according to Surescripts standard Formulary and Benefit Data Load
specification.
2. The Formulary Publisher sends Surescripts a formulary and benefit file on a
defined schedule that contains one or more of the formulary and benefit list types
(e.g. formulary status and/or alternatives). The Formulary and Benefit Data is
electronically transmitted to Surescripts via the selected file transfer method as a
single physical file.
3. Surescripts performs a physical validation of the file.
4. Surescripts sends the Formulary Response File back to the Publisher indicating
the Formulary and Benefit Data load status. The Response file indicates any
errors encountered in the load process.
5. The Formulary Publisher provides Surescripts with a Formulary Distribution List.
The Formulary Distribution List indicates which participants have access to which
formulary and benefit lists.
6. Surescripts separates the file into individual formulary and benefit lists,
processing each with its own list identifier. If there are no errors the lists are
loaded into the database.
7. Based on participant-to-participant contract relationships and the permissions
granted by the Formulary Publisher on the Distribution List, Surescripts makes
the appropriate subset of formulary status and alternatives lists available on the
WebDAV server for Formulary Retrievers to download.
PAGE 251
7.8
7.8.1
PAGE 252
and benefit file are U (Updates) or F (Full formulary replace). The options for
lists are F (Full list replace) or D (Delete the list).
Update Process:
After receiving the formulary and benefit files from the Formulary Publisher, the
Surescripts system checks each section of the file to validate that the data is
formatted correctly. If the data does not contain any errors, the file is loaded into
the Surescripts database as separate formulary and benefit lists for distribution. If
any of the lists were previously loaded in the database, the new lists replace the
existing ones, thereby updating the information. Any new information not previously
loaded in the database is added. However, if any of the data contains errors or
cannot be validated, that formulary and benefit list is not loaded, and an error is
sent to the Formulary Publisher within the Response File.
When a Formulary Publisher would like to notify its partners of the discontinuation
of a list, they send an action code of (D)elete within the list header and include no
detail rows in the list. The Formulary Retriever responds by removing the previously
loaded list with that ID.
Note: If the Formulary Publisher wants the Formulary Retriever to be notified of the
delete, they cannot remove access to the deleted list within the distribution list.
Full Replace Process:
With the Full Replace process, the new formulary and benefit file overwrites all the
previously loaded lists from that Formulary Publisher. Any formulary and benefit list
previously loaded in the database for that Publisher that is not included in the new
file is deleted. In this process, all file sections and data need to be error-free in
order to load the file. If there is any error at all found during the validation process,
no data in the file is loaded, the entire file is aborted, and an error is sent to the
Formulary Publisher within the Response File. Once the error is corrected, the
entire file must be resent and reprocessed. Note: full replace option should only be
used when all list types can be sent to Surescripts in one physical file.
7.8.2
ENVIRONMENT SETUP
Before sending formulary and benefit files to Surescripts, Formulary Publishers
need to set up a network connection to Surescripts and implement the selected file
transfer method within their environment. The network connection is set up and
configured as part of the regular implementation process with Surescripts. For more
information, refer to the Appendix B: Secure File Transfer.
7.8.3
PAGE 253
Formulary ID
Alternative List
Alternative ID
Coverage List
Coverage ID
Copay List
Copay ID
N/A
Classification ID
Example
/FSL/123451_20050301_20050318
/ALT/214312_20050301_20050318
/CRF/20050301_20050318
Coverage List
/COV/List id_effective date_extract date
/COV/ALFFT_20050301_20050318
Copay List
/COP/List id_effective date_extract date
/COP/SLCDE_20050301_20050318
/DCL/123DD_20050301_20050318
PAGE 254
Note: This structure assumes that the Formulary Retriever has access to files from
the following Formulary Publishers: ABC Corporation, and Benefit Management,
Inc..
Name
Size
Type
Modified
HEALTHA_20050301_20050318
30KB
File
3/12/2005
HEALTHB_20050301_20050318
24KB
File
3/12/2005
HEALTHC_20050301_20050318
100KB
File
3/12/2005
HEALTHA_20050301_20050317
630KB
File
3/12/2005
HEALTHB_20050301_20050317
362KB
File
3/12/2005
HEALTHC_20050301_20050317
424KB
File
3/12/2005
DSABCD_20050301_20050317
2230KB
File
3/12/2005
DSDFFG_220050301_0050317
242KB
File
3/12/2005
SLAAON_20050301_20050317
19KB
File
3/12/2005
ALABCD_20050301_20050317
877KB
File
3/12/2005
PATTHI_20050301_20050317
188KB
File
3/12/2005
QLFFVG_20050301_20050317
3900KB
File
3/12/2005
HEALTHD_20050301_20050316
630KB
File
3/11/2005
HEALTHE_20050301_20050316
362KB
File
3/11/2005
HEALTHG_20050301_20050316
424KB
File
3/11/2005
ABC
ALT
FSL
COP
COV
BMI
FSL
COV
QL1234_20050301_20050315
843KB
File
3/11/2005
QL11DE_20050301_20050315
128KB
File
3/11/2005
RL44DE_20050301_20050315
500KB
File
3/11/2005
PAGE 255
7.8.4
Participant ID:
List Date
enter
File Type:
PBMB
T0000000000xxxx
10/13/2003
DIS
Receiving Participant
Name
List Type
Coverage List
Type
List ID
Participant ID
enter
P0000001
FSL
1111
P0000001
FSL
2222
P0000001
FSL
3333
POC_A Company
P0000002
ALT
4444
Access rights are tracked at the individual list level. For example, a particular
Formulary Retriever may be given access to Formulary Status Lists 1111, 2222,
and 3333, while another Formulary Retriever is given access for Alternative List
4444.
Publishers can use an All participants wildcard in the distribution list instead of a
particular Technology Provider participant ID to indicate that all Technology
Providers that have a formulary contract relationship with the Formulary Publisher
can access a particular list. In the same way, an All lists wildcard may also be
used to indicate that the named participant has access to all lists for that Publisher.
Wildcards take precedence over all other entries in the distribution list.
Surescripts updates its system according to the information provided by the
Publisher in the distribution list and validates that all Technology Providers included
in the list have Formulary Contract Relationships with the Publisher. The
Surescripts system also determines what has changed since the last distribution
and identifies the specific access changes (adds and deletes) that are reflected in
the list.
When an update has been made to the list, Surescripts re-runs the distribution
process, treating the Publishers complete, current set of formulary information as a
new load. If a particular Technology Provider has gained access to a file due to the
Publishers new access rules, Surescripts distributes the most recent version of the
list to them. If a Technology Provider loses access to a file in the new rules,
Surescripts removes the files from the participants folder. Surescripts also records
distribution lists that have references to lists that do not exist (for example, in cases
PAGE 256
where lists have been deleted). For more information, refer to the File Processing
Options section.
7.9
FORMULARY RETRIEVAL
Formulary Retrievers download Formulary Publisher information from Surescripts via
WebDAV. WebDAV is a series of extensions to HTTPS that allow users to manage
files on remote servers. Within the WebDAV context, a Formulary Publisher is the
Participant providing the data files. The Formulary Retriever is the Participant that is
accessing for review and retrieval purposes.
The Formulary Retriever downloads formulary and benefit data from WebDAV by an
automated or manual process on a periodic basis. Retrieval of the formulary and
benefit lists can be done by utilizing the WebDAV clients referenced in Appendix A of
this Implementation Guide, creating a script that periodically checks for updates to
formulary and benefit data, or by using both a WebDAV client and a script.
The frequency of updates to the formulary and benefit data depends on the
Formulary Publisher, but generally changes are made on a monthly or quarterly
basis. After the Formulary Retriever downloads the updated formulary and benefit
data, it is stored in the Retrievers database and then displayed to physicians based
on the Retrievers system presentation rules.
7.9.1
7.9.2
PAGE 257
3. Compare the WebDAV directories to look for changes in the formulary and
benefit lists.
a. Download the updated formulary and benefit lists to their database.
At the list header level there is an action code of F or D (delete).
b. For list with an F in the list header, the Retriever should do a full replace
of all the records in that list. Full Replaces occur at the list level, not at the
individual record level. All previous records will be replaced in this list.
c. A delete action specifies the Retriever should remove that list from their
formulary and benefit database.
7.9.3
PAGE 258
Must occur 1
PAGE 259
Copay Header
Copay List ID (907-BV) = AAAAA
Copay Detail
Copay ID (906-BU) = 11111
..
Copay Detail
Copay ID (906-BU) = 22222
..
Copay Trailer
Cross-Reference Header
Cross-Reference Detail
..
Cross-Reference Trailer
Must occur 1
PAGE 260
Description
Type
M/C
Notes
Record Type
AN 3/3
Value = HDR
Version/Release
Number
Sender ID
AN 1/2
10
AN 3/30
Sender Participant
Password
AN
10/10
Receiver ID
S00000000000001
AN 3/30
Source Name
AN 1/35
Transmission
Control Number
AN 1/10
Transmission
Date
Transmission
Time
Transmission File
Type
Transmission
Action
DT 8/8
CCYYMMDD
TM 8/8
HHMMSSDD
AN 1/3
AN 1/1
Extract Date
DT 8/8
AN 1/1
File Type
T=Test
P=Production
PAGE 261
Description
Type
M/C
Notes
Record Type
Total Records
AN 3/3
N 1/10
M
M
Value = TRL
Do not include the file header and
trailer in this count. Total Records in
file minus 2.
Description
Type
M/C
Notes
Record Type
AN 3/3
Value = FHD
Formulary ID
AN 1/10
Formulary Name
Non-Listed
Prescription
Brand Formulary
Status
AN 1/35
AN 1/2
C
M
Non-listed
Prescription
Generic
Formulary Status
AN 1/2
Non-listed Brand
Over The
Counter
Formulary Status
AN 1/2
U - Unknown
0 Not Reimbursable
1 Non Formulary
2 On Formulary (Not Preferred)
3 Preferred Level 1
4 Preferred Level 2
5 Preferred Level 3
Up to 99.
U - Unknown
0 Not Reimbursable
1 Non Formulary
2 On Formulary (Not Preferred)
3 Preferred Level 1
4 Preferred Level 2
5 Preferred Level 3
Up to 99.
U - Unknown
0 Not Reimbursable
1 Non Formulary
2 On Formulary (Not Preferred)
3 Preferred Level 1
4 Preferred Level 2
5 Preferred Level 3
Up to 99.
PAGE 262
Field
Description
Type
M/C
Notes
Non-listed
Generic Over
The Counter
Formulary Status
AN 1/2
Non-listed
Supplies
Formulary Status
AN 1/2
Relative Cost
Limit
N 1/2
U - Unknown
0 Not Reimbursable
1 Non Formulary
2 On Formulary (Not Preferred)
3 Preferred Level 1
4 Preferred Level 2
5 Preferred Level 3
Up to 99.
U - Unknown
0 Not Reimbursable
1 Non Formulary
2 On Formulary (Not Preferred)
3 Preferred Level 1
4 Preferred Level 2
5 Preferred Level 3
Up to 99.
Note, if relative value is not used in
the detail, this value is 0 (zero).
List Action
AN 1/1
DT 8/8
List Effective
Date
Description
Type
M/C
Notes
Record Type
Change Identifier
AN 3/3
AN 1/1
M
M
Product/Service
ID
Product/Service
ID Qualifier
Drug ID (NDC)
AN 1/19
Value = FDT
A Addition
C Change
D - Delete
Surescripts requires N 11/11
Drug ID qualifier
AN 2/2
Drug Reference
Number
Drug Reference
Qualifier
AN 1/35
AN 1/3
PAGE 263
Field
Description
Type
M/C
Notes
RxNorm Code
AN 1/15
RxNorm Qualifier
AN 1/3
AN 1/2
N 1/2
U - Unknown
0 Not Reimbursable
1 Non Formulary
2 On Formulary (Not Preferred)
3 Preferred Level 1
4 Preferred Level 2
5 Preferred Level 3
Up to 99.
Represents the cost of the drug to
the health plan. If used, the relative
value limit in the header must be
greater than 0 and this value must
be less than or equal to the header
value.
Formulary Status
Relative Cost
Description
Type
M/C
Notes
Record Type
Total Records
AN 3/3
N 1/10
M
M
Value = FTR
Do not include the Header and
Trailer records in this count. Total
of Detail records.
Description
Type
M/
C
Notes
Record Type
AN 3/3
Value = XHD
List Effective
Date
List Action
DT 8/8
CCYYMMDD
AN 1/1
PAGE 264
Description
Type
M/
C
Notes
Record Type
AN 3/3
Value = XDT
Change
Identifier
AN 1/1
A Addition
C Change
D - Delete
AN
1/35
AN
1/10
AN
1/10
Coverage List
ID
Copay List ID
Classification ID
AN
1/10
AN
1/10
AN
1/10
Type
M/
C
Notes
Value = XTR
Description
Record Type
Record Count
AN 3/3
N 1/10
Description
Type
M/
C
Notes
Record Type
AN 3/3
Value = AHD
Alternative ID
AN
1/10
PAGE 265
Field
Description
Type
M/
C
Notes
List Action
AN 1/1
DT 8/8
Description
Type
M/
C
Notes
Record Type
AN 3/3
Value = ADT
Change Identifier
AN 1/1
Product/Service
ID - Source
Drug ID (NDC)
AN
1/19
Product/Service
ID Qualifier
Drug ID qualifier
AN 2/2
A Addition
C Change
D - Delete
Surescripts requires N 11/11
Note: Alternatives identified in a
formulary alternatives list indicate a
drug at the drug
name level only not the specific drug
name/strength/dosage form level
implied by the
NDC used to identify the alternative.
01 = Universal Product Code (UPC)
02 = Health Related Item (HRI)
03 = National Drug Code (NDC) - This
can be the representative NDC
Number. (Only NDCs are
supported by Surescripts
09 = Health Care Financing
Administration Common Procedural
Coding System (HCPCS)
28 = Universal Product Number (UPN)
Drug Reference
Number - Source
AN
1/35
Drug Reference
Qualifier Source
RxNorm Code Source
AN 1/3
AN
1/15
RxNorm Qualifier
- Source
Product/Service
ID - Alternative
AN 1/3
AN
1/19
PAGE 266
Field
Description
Type
M/
C
Notes
Product/Service
ID Qualifier
Drug ID qualifier
AN 2/2
Drug Reference
Number Alternative
Drug Reference
Qualifier Alternative
RxNorm Code Alternative
RxNorm Qualifier
- Alternative
Preference Level
AN
1/35
AN 1/3
AN
1/15
AN 1/3
N 1/2
Description
Type
M/
C
Notes
Record Type
Total Records
AN 3/3
N1/10
M
M
Value = ATR
Do not include Header and Trailer records in
this count. Total of Detail records.
Description
Type
M/
C
Notes
Record Type
Classification ID
AN 3/3
AN
1/10
M
M
Value = LHD
Must be unique across all lists of this type.
Valid characters are (A-Z, a-z, Numeral 0-9,
period ., and a dash -)
PAGE 267
List Action
AN 1/1
DT 8/8
Description
Type
M/
C
Notes
Record Type
Change Identifier
AN 3/3
AN 1/1
M
M
Product/Service
ID
Drug ID (NDC)
AN
1/19
Product/Service
ID Qualifier
Drug ID qualifier
AN 2/2
Value = LDT
A Addition
C Change
D - Delete
Surescripts requires N 11/11. Drug Number
categorized within this Class ID and
Subclass ID
01 = Universal Product Code (UPC)
02 = Health Related Item (HRI)
03 = National Drug Code (NDC) - This can
be the representative NDC Number.
09 = Health Care Financing Administration
Common Procedural Coding System
(HCPCS)
28 = Universal Product Number (UPN)
Drug Reference
Number
AN
1/35
AN 1/3
ID From RxNorm
database.
AN
1/15
Drug Reference
Qualifier
RxNorm Code
PAGE 268
Field
Description
Type
M/
C
Notes
RxNorm Qualifier
AN 1/3
N 1/5
N 1/5
AN
1/50
AN
1/50
Class ID
Subclass ID
Class Name
Subclass Name
Field Name
Type
M/C
Comments
Record Type
AN 3/3
Value = LTR
Record Count
N 1/10
Description
Type
M/C
Notes
Record Type
Coverage List ID
AN 3/3
AN 1/10
M
M
Coverage List
Type
AN 1/2
Value = GHD
Must be unique across all lists of this
type.
Valid characters are (A-Z, a-z, Numeral
0-9, period ., and a dash -)
Each Coverage List ID will have only one
List Type - Coverage associated within it.
AL = Age Limits
DE = Product Coverage Exclusion
GL = Gender Limits
MN = Medical Necessity
PA = Prior Authorization
QL = Quantity Limits
RD = Resource Link Drug-Specific
Level
RS = Resource Link Summary Level
SM = Step Medication
ST = Step Therapy
TM = Coverage Text Message
PAGE 269
Field
Description
Type
M/C
Notes
List Action
AN 1/1
DT 8/8
7.16.1.1
Field
Description
Type
M/C
Notes
Record Type
AN 3/3
Value = TDT
Change Identifier
AN 1/1
Coverage ID
The membership
population to which the
coverage rule applies.
Drug ID (NDC)
AN 1/40
A Addition
C Change
D - Delete
Relates to the Coverage ID returned in
the Surescripts Eligibility response.
AN 1/19
Drug ID qualifier
AN 2/2
AN 1/35
AN 1/3
AN 1/15
AN 1/3
AN
1/100
AN
1/200
Product/Service
ID
Product/Service
ID Qualifier
Drug Reference
Number
Drug Reference
Qualifier
RxNorm Code
RxNorm Qualifier
Message Short
Message - Long
PAGE 270
7.16.1.2
Field
Description
Record Type
Change Identifier
Coverage ID
Product/Service
ID
Product/Service
ID Qualifier
Drug Reference
Number
Drug Reference
Qualifier
RxNorm Code
RxNorm Qualifier
7.16.1.3
Type
M/
C
Notes
AN 3/3
Value = DDT
AN 1/1
The membership
population to which
the coverage rule
applies.
Drug ID (NDC)
AN 1/40
A Addition
C Change
D - Delete
Relates to the Coverage ID returned in
the Surescripts Eligibility response.
AN 1/19
Drug ID qualifier
AN 2/2
AN 1/35
AN 1/3
AN 1/15
AN 1/3
Field
Description
Type
M/
C
Notes
Record Type
Change Identifier
AN 3/3
AN 1/1
M
M
Coverage ID
The membership
population to which the
coverage rule applies.
Drug ID (NDC)
AN
1/40
Value = MDT
A Addition
C Change
D - Delete
Relates to the Coverage ID returned in
the Surescripts Eligibility response.
AN
1/19
AN 2/2
Product/Service ID Source
Product/Service ID
Qualifier - Source
Drug ID qualifier
PAGE 271
Field
Description
Type
M/
C
Notes
supported by Surescripts
09 = Health Care Financing
Administration Common Procedural
Coding System (HCPCS)
28 = Universal Product Number (UPN)
Drug Reference
Number - Source
Drug Reference
Qualifier - Source
AN
1/35
AN 1/3
Product/Service ID
Qualifier Step
Drug
Drug Reference
Number Step Drug
Drug Reference
Qualifier Step
Drug
RxNorm Code
Step Drug
RxNorm Qualifier
Step Drug
Drug Qualifier - Step
Drug
Subclass ID - Step
Drug
Number of Drugs to
Try
LAST PUBLISHED 4/15/11
C
C
AN
1/19
Drug ID qualifier
AN 2/2
AN
1/35
AN 1/3
AN
1/15
AN 1/3
AN
1/15
AN 1/3
AN 2/2
N 1/5
N 1/5
N 1/2
PAGE 272
Field
Description
Type
M/
C
or pharmacological class.
Step Order
Diagnosis Code
Diagnosis Code
Qualifier
7.16.1.4
Notes
Qualifier - Step Drug = PC
AN 1/1
AN
1/15
AN 2/2
C
C
1 = First to be tried
2 = second to be tried etc.
00 - Not Specified
01 - International Classification of
th
Diseases (ICD9) - the 9 edition
02 - International Classification of
th
Diseases (ICD10) - the 10
edition
03 - National Criteria Care Institute
(NCCI)
04 - The Systematized Nomenclature
of Human and Veterinary
Medicine (SNOMED)
05 - Common Dental Terminology
(CDT)
06 - First DataBank MDDB Product
Line
07 - American Psychiatric Association
Diagnostic Statistical Manual of
Mental Disorders (DSM IV)
99 - Other
Field
Description
Type
M/C
Notes
Record Type
Identifies record
type.
Only the Add option
is accepted.
AN 3/3
Value = QDT
AN 1/1
The membership
population to which
the coverage rule
applies.
Drug ID (NDC)
AN 1/40
A Addition
C Change
D - Delete
Relates to the Coverage ID
returned in the Surescripts
Eligibility response.
AN 1/19
Change Identifier
Coverage ID
Product/Service ID
PAGE 273
Field
Description
Type
M/C
Notes
Product/Service ID
Qualifier
Drug ID qualifier
AN 2/2
Drug Reference
Number
AN 1/35
AN 1/3
AN 1/15
AN 1/3
R 1/10
C required if
Maximum
Amount
Qualifier is
present.
AN 2/2
C required if
Maximum
Amount is
present.
Drug Reference
Qualifier
RxNorm Code
RxNorm Qualifier
Maximum Amount
Maximum Amount
Qualifier
PAGE 274
Field
Description
Type
M/C
AN 2/2
C required if
Maximum
Amount
Qualifier is
NOT DS
(Days Supply),
Optional if
Maximum
Amount
Qualifier is
DS.
DT 8/8
Ending date of
Specific Date
Range
DT 8/8
Number of units
associated with the
overall Time Period
N 1/4
C required if
Time Period =
SP, otherwise
not populated.
C required if
Time Period =
SP,
otherwise not
populated.
C required if
Maximum
Amount Time
Period = DY,
CQ CY or
CM otherwise
not populated.
7.16.1.5
Notes
CCYYMMDD
CCYYMMDD
Field
Description
Type
M/C
Notes
Record Type
AN 3/3
Value = GDA
Change
Identifier
AN 1/1
Coverage ID
The membership
population to which the
coverage rule applies.
Drug ID (NDC)
AN 1/40
AN 1/19
A Addition
C Change
D - Delete
Relates to the Coverage ID
returned in the Surescripts
Eligibility response.
Surescripts requires N 11/11
Product/Serv
ice ID
PAGE 275
Field
Description
Type
M/C
Notes
Product/Serv
ice ID
Qualifier
Drug ID qualifier
AN 2/2
Drug
Reference
Number
Drug
Reference
Qualifier
RxNorm
Code
RxNorm
Qualifier
Minimum
Age
AN 1/35
AN 1/3
AN 1/15
AN 1/3
N 1/3
Minimum
Age Qualifier
AN 1/1
Maximum
Age
N 1/3
Maximum
Age Qualifier
AN 1/1
C, if Minimum
Age Qualifier is
populated
C, if Minimum
Age is
populated
C, if Maximum
Age Qualifier is
populated
C, if Maximum
Age is
populated
7.16.1.6
D = Days
Y = Years
If maximum does not apply,
leave blank
D = Days
Y = Years
Field
Description
Type
M/C
Notes
Record Type
Change
Identifier
AN 3/3
AN 1/1
M
M
Coverage ID
The membership
population to which the
coverage rule applies.
Drug ID (NDC)
AN 1/40
Value = GDT
A Addition
C Change
D - Delete
Relates to the Coverage ID returned in
the Surescripts Eligibility response.
AN 1/19
Product/Servi
ce ID
PAGE 276
Field
Description
Type
M/C
Notes
Product/Servi
ce ID
Qualifier
Drug ID qualifier
AN 2/2
Drug
Reference
Number
Drug
Reference
Qualifier
RxNorm
Code
RxNorm
Qualifier
Gender
AN 1/35
AN 1/3
AN 1/15
AN 1/3
AN 1/1
1 = Male
2 = Female
7.16.1.7
Field
Description
Type
M/C
Notes
Record Type
Change
Identifier
AN 3/3
AN 1/1
M
M
Coverage ID
The membership
population to which the
coverage rule applies.
Identifies the type of
coverage information
contained at the URL listed
below.
AN 1/40
Value = RDT
A Addition
C Change
D - Delete
Relates to the Coverage ID returned in
the Surescripts Eligibility response.
AN 2/2
AN 1/255
Resource
Link Type
URL
7.16.1.8
AL - Age Limits
DE - Product Coverage Exclusion
GL - Gender Limits
MN - Medical Necessity
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
GI - General Info
CP - Copay
FM - Formulary
Only one URL may be associated with
each Coverage ID / resource type
combination.
Field
Description
Type
M/C
Notes
Record Type
Change Identifier
AN 3/3
AN 1/1
M
M
Value = RRT
A Addition
C Change
D - Delete
PAGE 277
Field
Description
Type
M/C
Notes
Coverage ID
The membership
population to which the
coverage rule applies.
Drug ID (NDC)
AN 1/40
AN 1/19
Drug ID qualifier
AN 2/2
AN 1/35
AN 1/3
AN 1/15
AN 1/3
Resource Link
Type
AN 2/2
URL
AN 1/255
AL - Age Limits
DE - Product Coverage Exclusion
GL - Gender Limits
MN - Medical Necessity
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
GI - General Info
CP - Copay
FM - Formulary
Only one URL may be associated
with each coverage id / resource
type combination.
Product/Service
ID
Product/Service
ID Qualifier
Drug Reference
Number
Drug Reference
Qualifier
RxNorm Code
RxNorm Qualifier
Description
Type
M/C
Notes
Record Type
AN 3/3
Value = GTR
Record Count
N 1/10
PAGE 278
Description
Type
M/C
Notes
Record Type
Copay List ID
AN 3/3
AN 1/10
M
M
AN 1/2
Value = CHD
Must be unique across all lists of
this type.
Valid characters are (A-Z, a-z,
Numeral 0-9, period ., and a dash
-)
SL Summary Level
DS Drug Specific
List Action
AN 1/1
DT 8/8
7.17.1.1
Field
Description
Type
M/C
Notes
Record Type
AN 3/3
Value = CDT
Change Identifier
AN 1/1
Copay ID
The membership
population to which the
Copay rule applies.
AN 1/40
Formulary Status
AN 1/2
A Addition
C Change
D - Delete
Relates to the Copay ID
returned in the
Surescripts Eligibility
response.
1 Non-Formulary
2 On Formulary (Not
Preferred)
3 - Preferred Level 1
4 Preferred Level 2
Up to 99
Note: 0 (NonReimbursable) is not
allowed
A = Any
PAGE 279
Field
Description
Type
M/C
Notes
Product Type
AN 1/1
Pharmacy Type
AN 1/1
Out of Pocket
Range Start
R 1/10
Out of Pocket
Range End
R 1/10
0 = Not Specified
1 = Single source brand
2 = Branded generic
3 = Generic
4 = O.T.C. (over the
counter)
5 = Compound
6 = Supply
7= Multi source brand
A = Any
R = Retail
M = Mail Order
S = Specialty
L = Long-term Care
A = Any
No dollar sign. Decimal
required if value includes
cents. Currency: USD
The length includes the
decimal point.
No dollar sign. Decimal
required if value includes
cents. Currency: USD
The length includes the
decimal point.
Flat Copay
Amount
R 1/10
Percent Copay
Rate
R 1/10
AN 1/1
Minimum Copay
R 1/10
C at least one of
the following
fields must be
populated: Flat
Copay Amount,
Percent Copay
Rate, or Copay
Tier
C - at least one
of the following
fields must be
populated: Flat
Copay Amount,
Percent Copay
Rate, or Copay
Tier
C if both Flat
Copay and
Percent Copay
are populated
C if Percent
Copay is
populated
Percentage expressed
as a decimal (e.g., 0.0
through 1.0 represents
0% through 100%)
The length includes the
decimal point.
F = Flat Copay
P = Percent Copay
PAGE 280
Field
Description
Type
M/C
Notes
Maximum Copay
R 1/10
C if Percent
Copay is
populated
N 1/3
N 1/2
N 1/2
C - at least one
of the following
fields must be
populated: Flat
Copay Amount,
Percent Copay
Rate, or Copay
Tier
C if Copay
Tier is
populated
Copay Tier
Maximum Copay
Tier
7.17.1.2
Field
Description
Type
M/C
Notes
Record Type
Change Identifier
AN 3/3
AN 1/1
M
M
Copay ID
The membership
population to which the
Copay rule applies.
AN 1/40
Product/Service
ID
Product/Service
ID Qualifier
Drug ID (NDC)
AN 1/19
Drug ID qualifier
AN 2/2
Value = CRT
A Addition
C Change
D - Delete
Relates to the Copay ID
returned in the
Surescripts Eligibility
response.
Surescripts requires N
11/11
01 = Universal Product
Code (UPC)
02 = Health Related Item
(HRI)
03 = National Drug Code
(NDC) - This can be the
representative NDC
Number. (Only NDCs
are supported by
Surescripts
09 = Health Care
Financing Administration
Common Procedural
Coding System (HCPCS)
28 = Universal Product
Number (UPN)
Drug Reference
Number
Drug Reference
Qualifier
AN 1/35
AN 1/3
PAGE 281
Field
Description
Type
M/C
Notes
RxNorm Code
ID from RxNorm
database.
Code qualifying the
RxNorm code submitted.
Dispensing pharmacy type
AN 1/15
AN 1/3
AN 1/1
Flat Copay
Amount
R 1/10
Percent Copay
Rate
R 1/10
AN 1/1
Minimum Copay
R 1/10
C - at least one
of the following
fields must be
populated: Flat
Copay Amount,
Percent Copay
Rate, or Copay
Tier
C - at least one
of the following
fields must be
populated: Flat
Copay Amount,
Percent Copay
Rate, or Copay
Tier
C if both Flat
Copay and
Percent Copay
are populated
C if Percent
Copay is
populated
Maximum Copay
R 1/10
C if Percent
Copay is
populated
N 1/3
N 1/2
C - at least one
of the following
fields must be
populated: Flat
Copay Amount,
Percent Copay
Rate, or Copay
Tier
C if Copay
Tier is
populated
RxNorm Qualifier
Pharmacy Type
Copay Tier
Maximum Copay
Tier
N 1/2
Percentage expressed
as a decimal (e.g., 0.0
through 1.0 represents
0% through 100%)
The length includes the
decimal point.
F = Flat Copay
P = Percent Copay
PAGE 282
Description
Type
M/C
Notes
Record Type
Record Count
AN 3/3
N 1/10
M
M
Value = CTR
Do not include the Copay
Header and Trailer
records in this count.
Total of Copay
Information Detail
records.
PAGE 283
For more information on Full Replaces vs. Updates, refer to the File Processing
Options section.
Must occur 1
Occurs 0 if no errors or system error
Occurs 1 to n if errors
Must occur 1
PAGE 284
Description
Type
M/
C
Notes
Record Type
Version/Releas
e Number
Sender ID
AN 3/3
AN 1/2
M
M
Value = SHD
10
AN
3/30
AN
3/30
AN
10/10
AN
1/10
Recipient ID
Recipient
Participant
Password
Transaction
Control Number
Transaction
Date
Transaction
Time
Transaction File
Type
Transaction
Number Originating
Transaction
DateOriginating
DT 8/8
CCYYMMDD
TM 8/8
HHMMSSDD
AN 1/3
AN
1/10
DT 8/8
CCYYMMDD
Transaction
TimeOriginating
File Type
TM 8/8
HHMMSSDD
AN 1/1
T=Test
P=Production
PAGE 285
Field
Description
Type
M/
C
Notes
Load Status
AN 2/2
Detail Info
Field
Description
Type
M/C
Notes
Record Type
AN
3/3
Value = SDT
Absolute Row
Number
N
1/10
Section
Column in
Error
N 1/2
Reject Code
AN
4/4
AN
1/100
AN
1/100
Additional
Message
Information
Data in Error
PAGE 286
Trailer Info
Field
Description
Type
M/C
Notes
Record Type
AN
3/3
N
1/10
N
1/10
Value = STR
Total Rows in
Error
Total Errors
M
M
Explanation
1001
1002
1003
1004
Unknown segment
Unexpected segment
1005
1006
1007
1008
1009
1010
1011
1012
1013
9000
If a detail row contains an error within an Update process, the entire occurrence of
that section (List) is not loaded. However, the processing for the rest of the file
continues.
If a detail row contains an error within a Full Replace process, the processing of the
entire file (not just the list that contained the error) is stopped and the entire file is
rejected.
PAGE 287
PAGE 288
7.20.1.1
Formula
ry ID
NonListed
Generic
Over The
Counter
Formular
y Status
FHD
100
HealthOn U
e National
Formulary
20050101
FDT
Product
/
Service
ID
0002932
0613
Product / Drug
Drug
RxNorm
Service
Reference Reference Code
ID
Number
Qualifier
Qualifier
03
Record Count
FTR
Raw Data:
FHD|100|HealthOne National Formulary|U|U|U|U|U|0|F|20050101
FDT.
FDT|A|0029320613|03|||||2
FDT.
FTR|3
PAGE 289
Step one: Retrieve the patients payers participant ID (P00010), and Formulary ID
(100) from the 271 transaction.
Step two: Search Formulary Status List 100 for the medication, looking for the
products NDC in the Product / Service ID field. The medications NDC cannot be
found
Step three: Refer to the Non-Listed Prescription Brand Formulary Status field in
the Formulary Status List Header record. That value applies to this medication: 2
On Formulary
The following shows excerpted example content.
7.20.2.1
Formula
ry ID
NonListed
Brand
Over The
Counter
Formulary
Status
NonListed
Generic
Over The
Counter
Formular
y Status
FHD
100
HealthOn 2
e National
Formulary
20050101
Product
/
Service
ID
FDT
Product /
Service
ID
Qualifier
Drug
Drug
RxNorm
Reference Reference Code
Number
Qualifier
Record Count
FTR
Raw Data:
FHD|100| HealthOne National Formulary|2|3|1|2|0|0|F|20050101
FDT.
FDT
FTR|..
PAGE 290
When a payer utilizes the Product Coverage Exclusion list, an additional pre-step is
added to the formulary lookup process. Before consulting the Formulary Status List,
the user searches the Product CoverageExclusion list for the patients Coverage ID
and the medication being considered.
Step one: Retrieve the patients payers participant id (P00010), Formulary ID
(100), and Coverage ID (2222) from the 271 transaction.
Step two: Confirm theres no product coverage exclusion for medication being
considered, by searching the Product Coverage Exclusion list for the Coverage ID
2222 and the medications ID (Paroxetine HCL 12.5 mg Tablet, NDC = 000293206-13).
If the Coverage ID / Drug ID combination is present, the process stops. The
patients membership group does not cover the medication, and the Formulary
Status is equal to 0 Not Reimbursable.
The following shows excerpted example content.
7.20.3.1
Coverage List ID
Coverage List
Type
GHD
HEALTHONE
DE
20050101
GDT
Change
Identifier
Coverag Product /
e ID
Service ID
2222
Product /
Service ID
Qualifier
Drug
Reference
Number
Drug
Reference
Qualifier
00029320613 03
Record Count
GTR
Raw Data:
GHD|HEALTHONE|DE|F|20050101
GDT|A|2222|000293320613|03
GTR|..
PAGE 291
On its Formulary Status List, the payer includes one NDC for each label name
medicationrepresenting that drug name / strength / dosage form combination.
In the example below, the payer has included just one NDC11 to represent Zyprexa
10 mg Tablet, though there are multiple package variations for the medication (a 60
count bottle, a 1,000 count bottle, and a unit dose pack, along with other variations
offered by repackagers). Following the guidelines set out elsewhere in this guide,
the payer included an NDC which is (a) not repackaged, (b) not obsolete, and (c)
not a unit dose pack.
Note: The payer in this example does not employ the Product Coverage Exclusion
list. See a separate example in this section for an illustration of its use.
Below is a conceptual process for locating a medication within a Formulary Status
List containing representative NDCs. Note that different system implementations of
this logical process are possible.
Step one: Retrieve the patients payers participant ID (P00010), and Formulary ID
(100) from the 271 transaction.
Step two: Reference a third-party or proprietary drug database to gather all NDCs
associated with the prescription-level medication being considered:
Step three: Search Formulary Status List 100 for each NDC gathered in the
preceding step. Once a match is made, note the Formulary Status.
In this example, the third NDC was listed by the payer: 00002-4117-60, with a
Formulary Status value of 2.
Therefore, the formulary status for the label name drug, Zyprexa 10 mg Tablet, is 2
On-Formulary.
The following shows excerpted example content.
7.20.4.1
Formula
ry ID
NonListed
Brand
Over The
Counter
Formulary
Status
NonListed
Generic
Over The
Counter
Formulary
Status
FHD
100
HealthOn U
e National
Formulary
2005010
1
Product
/
Service
Product / Drug
Drug
RxNorm
Service
Reference Reference Code
ID
Number
Qualifier
RxNorm
Qualifier
Formular Relative
y Status Cost
PAGE 292
FDT
ID
Qualifier
0000241
1760
03
Record Count
FTR
Raw Data:
FHD|100|HealthOne National Formulary|U|U|U|U|U|0|F|20050101
FDT.
FDT|A|00002411760|03|||||2
FDT
FTR|..
00093-0822-01 Nifedipine ER
00069-1520-68 Norvasc
7.20.5.1
Alternative
List ID
List
Action
AHD
100
20050506
Alternative Detail
LAST PUBLISHED 4/15/11
PAGE 293
ADT
ADT
A
A
00004018091
00004018091
Alternative NDC
00093082201
00069152068
Preference
Level
4
3
ATR
Raw Data:
AHD|100|F|20050506
ADT|.
ADT|A|00004018091|00093082201|4
ADT|A|00004018091|00069152068|3
ADT|.
ATR|4
PAGE 294
7.20.6.1
Coverage List ID
Coverage List
Type
GHD
HEALTHONE
GL
20050101
Change
Identifier
Coverag Product /
e ID
Service ID
GDT
2222
Product /
Service ID
Qualifier
Drug
Reference
Number
54868467900 03
Drug
Reference
Qualifier
Gender Code
Record Count
GTR
Raw Data:
GHD|HEALTHONE|GL|F|20050101
GDT
GDT|A|2222|54868467900| 03|||2
GDT
GTR|
LAST PUBLISHED 4/15/11
PAGE 295
7.20.6.2
Coverage List ID
Coverage List
Type
GHD
HEALTHONE
QL
20050101
GDT
Chang
e
Identifi
er
Covera
ge ID
Product /
Service ID
Product Drug
Drug
Maximu
/ Service Referenc Reference m
ID
e Number Qualifier Amount
Qualifier
2222
54868467900 03
30
Maximu
m
Amount
Qualifier
Maximu
m
Amount
Time
Period
DS
Record Count
GTR
Raw Data:
GHD|HEALTHONE|QL|F|20050101
GDT
GDT|A|2222|54868467900|03|||30|DS
GDT
GTR|
In the example, the payer has identified a single step requirement; if more than one
step had been listed, then the Step Order data element would indicate which step
should be tried first, second, etc.
LAST PUBLISHED 4/15/11
PAGE 296
Step Medications:
o Class ID - Step Drug = 156
o Subclass ID - Step Drug = 156-22
o Step Order = 1
o Number of Drugs to Try = 1
Step three: Locate a drug of the class / subclass indicated in the Step Medications
match:
7.20.7.1
Coverage List ID
Coverage List
Type
GHD
HEALTHONE
SM
20050101
GDT
Chang
e
Identifi
er
Coverag
e ID
Source
Product /
Service ID
Product /
Service ID
Qualifier
Step
Order
2222
00025198031
03
156
156-22
Record Count
GTR
Raw Data:
GHD|HEALTHONE|SM|F|20050101
GDT
GDT|A|2222|00025198031| 03||156|156-22|1|1
GDT
GTR|
LAST PUBLISHED 4/15/11
PAGE 297
7.20.7.2
Classification ID
LHD
20050101
LDT
Product /
Service ID
Product / Drug
Drug
Class ID Subclas Class Name Subclass
Service ID Referenc Referenc
s ID
Name
Qualifier e Number e
Qualifier
0024714232 03
0
156
156-22
Record Count
LTR
Raw Data:
LHD|A|F|20050101
LDT...
LDT|A|00247142320|03|||156|156-22|Drugs Acting Principally On Joints
|NSAIDS, Cox-1 Inhibitor
LDT
LTR|
PAGE 298
Copay ID = COP300
NDC# = 50458-0320-06 (Risperdal 2 mg Tablet)
One match is made, specifying the copay that applies when dispensed at any type
of pharmacy.
For illustration, the example content below also contains the summary-level copay
that represented the general rule (which was overridden in this scenario):
7.20.8.1
Copay List ID
CHD
HEALTHONE
DS
20050101
Change
Identifier
Copay
ID
Source
Product /
Service ID
Product /
Service ID
Qualifier
CRT
COP300 50458032006 03
Pharmacy
Type
Flat Copay
Amount
10
Copay Trailer
Record Type
Record Count
CTR
PAGE 299
Raw Data:
CHD|HEALTHONE|DS|F|20050101
CRT
CRT|A|COP300|50458032006|03||A|10
CRT..
CTR|
7.20.8.2
Copay List ID
CHD
HEALTHONE
SL
20050101
CDT
Change
Identifier
Copay
ID
Formular Product
y Status Type
COP300 A
20
Copay Trailer
Record Type
Record Count
CTR
Raw Data:
CHD|HEALTHONE|SL|F|20050101
CDT
CDT|A|COP300|A|1|A|20
CDT..
CTR|
PAGE 300
The steps below locate the copay information. The example assumes the user is
considering a single-source branded prescription medication.
Step one: Retrieve the patients payers participant ID (P00010), Formulary ID
(100) and Copay List ID (COP300)
Step two: Search the Copay Information Detail Drug-Specific list to determine
whether a drug-specific copay was provided by the payer. In this example, no drugspecific rule was supplied
Step three: Search the Copay Information Detail Summary Level list to find the
general rule for branded medications
In the matching entry in the Copay Information Detail Summary Level list, the rule
described above is represented as
7.20.9.1
Copay List ID
CHD
HEALTHONE
SL
20050101
CDT
Change
Identifi
er
Copa
y ID
COP3 A
00
Flat
Copay
Amount
Percen First
t
Copay
Copay Term
Rate
Minimu Maximu
m
m
Copay Copay
10
0.15
10
Copay Trailer
Record Type
Record Count
CTR
PAGE 301
30
Raw Data:
CHD|HEALTHONE|SL|F|20050101
CDT
CDT|A|COP300|A|1|A| |10|0.15|F|10|30
CDT..
CTR|
7.20.10
In this example, the patients health plan varies the patient copay based on their
current out-of-pocket balance the amount that the patient has contributed, todate, to the cost of their medications.
The illustration below presents a copay plan with different patient copays for the
three conditions below:
If the patient has contributed less than $100 to-date, their copay is $30
If the patients out-of-pocket balance is between $100 and $1,000, their
copay is $20
Lastly, if the patients out-of-pocket balance is greater than $1,000, their
copay is $10
Second record
PAGE 302
Third record
7.20.10.1
Copay List ID
CHD
HEALTHONE
SL
20050101
Change
Identifier
ID
y Status t Type Type
pocket pocket Copay
Range Range Amoun
Start End
t
CDT
CDT
CDT
COP3
00
COP3
00
COP3
00
100
30
100.01 1000
20
1000.0
1
10
Copay Trailer
Record Type
Record Count
CTR
Raw Data:
CHD|HEALTHONE|SL|F|20050101
CDT
CDT|A|COP300|A|A|A|0|100|30
CDT|A|COP300|A|A|A|100.01|1000|20
PAGE 303
CDT|A|COP300|A|A|A|1000.01||10
CDT..
CTR|
7.20.11
This example describes how the new Medicare prescription drug benefits out-ofpocket rules would be represented in the Benefit Copay Lists. The patients copay
varies from 100% down to 5% based on their current out-of-pocket balance the
amount that the patient has contributed, year-to-date, to the cost of their
medications.
The figure below illustrates how a patients out-of-pocket balance accumulates
according to drug purchases:
Range
Dollar cost in
end
range
250
250
2,250
2,000
5,100
2,850
unlimited
n/a
Patient's out-of-pocket
Percent
copay
100%
25%
100%
5%
For range
250
500
2,850
5% of add'l
Accumulated
250
750
3,600
3,600 + 5% of
add'l drug costs
If the patient has contributed less than $250 to-date, their copay is 100%
of the cost of the drug
If the patients out-of-pocket balance is between $250 and $750, their
copay is 25% of the cost of the drug
If the patients out-of-pocket balance is between $750 and $3,600, their
copay goes back up to 100% of the cost of the drug
Lastly, once the patients out-of-pocket balance exceeds $3,600, their
copay goes down to 5% of the cost of the medication
The steps below locate those copay rules. Note: In this example, HealthOne MN is
administering the patients Medicare benefit.
Step one: Retrieve the patients payers participant id (P00010), Formulary ID
(100) and Copay List ID (COP300) from the 271 transaction.
Step two: Search the Copay Information Detail - Drug-Specific list to determine
whether a drug-specific copay was provided by the payer. In this example, no drugspecific rule was supplied
Step three: Search the Copay Information Detail - Summary Level list to find the
general rule
LAST PUBLISHED 4/15/11
PAGE 304
The four matching entries in the Copay Information Detail - Summary Level list
codify the rule described above...
First record
Second record
Third record
Fourth record
PAGE 305
7.20.11.1
Copay List ID
CHD
HEALTHONE
SL
20050101
Chan
ge
Identi
fier
Copay
ID
CDT
CDT
250.01 750
0.25
CDT
750.01 3600
1.0
CDT
COP30
0
COP30
0
COP30
0
COP30
0
3600.0
1
0.05
250
1.0
Copay Trailer
Record Type
Record Count
CTR
Raw Data:
CHD|HEALTHONE|SL|F|20050101
CDT
CDT|A|COP300|A|A|A|0|250|1.0
CDT|A|COP300|A|A|A|250.01|750|0.25
CDT|A|COP300|A|A|A|750.01|3600|1.0
CDT|A|COP300|A|A|A|3600.01||0. 05
CDT..
CTR|
PAGE 306
7.20.12
This scenario contains a formulary status header record with an invalid file action of
X. The error returned in the response file is 1008 Field value not found in
validation table.
Formulary and Benefit File Header
Recor
d
Type
Versio Sende Sender Receive Receiver Source Transmis Transm Trans Trans Trans Extra File
n
r ID
Particip r ID
Participa Name sion
ission missio missio missi ct
Type
/Relea
ant
nt
Control Date
n Time n File on
Date
se
Passwo
Passwor
Number
Type Actio
Numbe
rd
d
n
r
HDR
01
ABC
PASS
XYZ
Publish 30011
er
PASS
20050 T
101
Formul
ary ID
Non-Listed
Prescriptio
n Generic
Formulary
Status
Non-Listed
Brand Over
The Counter
Formulary
Status
NonListed
Generic
Over The
Counter
Formulary
Status
FHD
100
HealthOn U
e National
Formulary
20050101
Change
Identifier
Product
/
Service
ID
Product Drug
/
Reference
Service Number
ID
Qualifie
r
FDT
5486846
7900
03
Drug
RxNorm RxNorm Formulary Relative
Referenc Code
Qualifier Status
Cost
e
Qualifier
Record Count
FTR
Total Records
TRL
PAGE 307
Raw Data:
HDR|01|ABC|PASS|XYZ|PASS|Publisher|30011|20050101|12053001|FRM|F|20050101|T
FHD|100|HealthOne National Formulary|||||| 0|X|20050101
FDT.
FDT|A|54868467900|03|||||2
FDT.
FTR|3
TRL|
SHD
01
PASS
XYZ
ABC
30011
20050101 12053001 T
03
Absolute
Row
Number
Section
Column
In Error
Reject
Code
SDT
10
1008
Total Errors
STR
Raw Data:
SHD|01|XYZ|ABC|PASS|445534|20050101|15053001|FRE|30011|20050101|15053001|T|0
3
SDT|2|10|1008|Field value not found in validation table |X
SRL|1|1
PAGE 308
7.20.13
This scenario contains a Coverage Information Detail Age Limits record. The
record contains the maximum age of 18, but not the qualifier of Y for years. The
error returned in the response file is 1006 Required Field Missing.
Formulary and Benefit File Header
Reco
rd
Type
Versio Sende Sender Receive Receiver Source Transmis Transm Trans Trans
n
r ID
Partici r ID
Particip Name sion
ission missio missio
/Relea
pant
ant
Control Date
n Time n File
se
Passw
Passwor
Number
Type
Numbe
ord
d
r
HDR
01
ABC
PASS
XYZ
PASS
Publish 30012
er
200501 T
01
Coverage List ID
Coverage List
Type
GHD
HEALTHONE
AL
20050101
GDA
Chan
ge
Identi
fier
Covera
ge ID
Product /
Service ID
Product
/ Service
ID
Qualifier
2222
54868467900 03
18
Record Count
GTR
Total Records
TRL
Raw Data:
HDR|01|ABC|PASS|XYZ|PASS|Publisher|30012|20050101|12053001|FRM|F|20050101|T
GHD|HEALTHONE|AL|F|20050101
GDA
GDA|A|2222|54868467900|03||||18
GDA
LAST PUBLISHED 4/15/11
PAGE 309
GTR|
TRL|
Formulary and Benefit Response File Header
Rec
ord
Typ
e
SH
D
01
XYZ
Trans
missi
on
File
Type
ABC PASS
20050101 12053001 T
03
Absolute
Row
Number
Section
Column
In Error
Reject
Code
Additional
Message
Information
SDT
13
1006
Required Field
Missing
Data In Error
Total Errors
STR
Raw Data:
SHD|01|XYZ|ABC|PASS|445535|20050101|15053001|FRE|30012|20050101|15053001|T|0
3
SDT|4|13|1006|Required Field Missing
SRL|1|1
7.20.14
This scenario contains a Coverage Information Detail Age Limits record. The
Coverage Information Header record is missing. The error returned in the response
file is 1004 Unexpected Segment.
Formulary and Benefit File Header
Rec
ord
Typ
e
Versio Sende Sender Receive Receiver Source Transmis Transm Trans Trans
n
r ID
Particip r ID
Particip Name sion
ission missio missio
/Relea
ant
ant
Control Date
n Time n File
se
Passwo
Passwor
Number
Type
Numbe
rd
d
r
HD
R
01
ABC
PASS
XYZ
PASS
Publish 30013
er
200501 T
01
PAGE 310
GDA
Chang
e
Identifi
er
Covera
ge ID
Product /
Service ID
Product
/ Service
ID
Qualifier
2222
54868467900 03
18
Record Count
GTR
Total Records
TRL
Raw Data:
HDR|01|ABC|PASS|XYZ|PASS|Publisher|30013|20050101|12053001|FRM|F|20050101|T
(MISSING)
GDA
GDA|A|2222|54868467900|03||||18
GDA
GTR|
TRL|
SHD
01
445536
30013
2005010 12053001
1
03
Absolute
Row
Number
Section
Column
In Error
Reject
Code
Additional Message
Information
SDT
1004
Unexpected Segment
Data In Error
Total Errors
STR
PAGE 311
Raw Data:
SHD|01|XYZ|ABC|PASS|445536|20050101|15053001|FRE|30013|20050101|15053
001|T|03
SDT|2|1|1004|Unexpected Segment
SRL|1|1
PAGE 312
PAGE 313
APPENDIX A:
WebDav Clients
WEBDAV CLIENTS
Surescripts has the ability to deliver provider directory and formulary and benefit files to its
Participants via WebDAV. WebDAV is a series of extensions to HTTP which allows users to
collaboratively edit and manage files on remote servers (more information on WebDAV can
be found at http://www.webdav.org).
This appendix is intended to give Surescripts Participants more information about the types
of WebDAV clients they can use to access Surescripts formulary and provider update
information.
WebDAV Clients
The WebDAV clients described in this appendix are being used by some Surescripts
Participants to access the Surescripts formulary and provider information. New
Participants may choose to use these or any other available WebDAV clients to
connect to the Surescripts WebDAV server.
WebDAV Client Support
Surescripts is not a developer or distributor of these WebDAV clients. Therefore, we
cannot provide extensive technical support for them.
If you are able to manually log in to WebDAV and download formulary data, this
confirms connectivity to Surescripts, and requires you to contact the support staff for
the WebDAV client you are using. Also, if you have problems installing or configuring
the clients in your environment, please call the WebDAV clients support staff.
Information such as the WebDAV URL, connectivity options, Participant User ID, and
Participant password are provided during the Participants implementation.
PAGE 314
WebDav Clients
GET
Retrieve a file
PROPFIND
OPTIONS
1.3.1.
SUPPORTED PLATFORMS
1.3.2.
INSTALLATION
There is no installation involved if you are running one of the above operating
systems or if Internet Explorer 5.x has been installed.
1.3.3.
First, open Internet Explorer, go to the File menu, and select Open. The following
dialog will appear; fill in the location shown below (https://filescert.rxhub.net/webdav/) and click the Open as Web Folder checkbox. Note: if an
error message appears before the login dialog, then there may be a DNS problem
on your computer. Sometimes, running the following command from a DOS prompt
helps: ipconfig /registerdns
PAGE 315
WebDav Clients
The Web Folders are displayed in a browser. You can simply drag and drop the
information within the folders from the browser window into a local directory
structure.
In the above example, clicking the Formulary folder will bring up folders for each type of
formulary and benefit list this PBM (Formulary Publisher) has given this POC (Formulary
Retriever) access to within WebDAV.
Clicking on a particular list folder (in this example, ALT) brings up the files of that
type.
PAGE 316
WebDav Clients
1.4. CADAVER
Cadaver is a UNIX command-line, open source WebDAV client. This client is ideal
for scripting an automated process to download WebDAV folder information onto a
UNIX system. For more information, visit the Cadaver
Homepage: http://www.webdav.org/cadaver/.
1.4.1.
SUPPORTED PLATFORMS
PAGE 317
1.4.2.
WebDav Clients
INSTALLATION
Before installing Cadaver, you must first install OpenSSL to get Cadaver working
with HTTPS support.
Open a web browser and navigate to the website: http://www.openssl.org/source/
Download OpenSSL, gunzip it, and untar it.
cd to the OpenSSL root install directory and do the following:
$ ./config
$ make
$ make test
$ make install (this will most likely need to be run as root)
Go to http://www.webdav.org/cadaver/ to download Cadaver.
o
o
o
1.4.3.
PAGE 318
WebDav Clients
When in a file directory, you may download files by issuing the get or the mget
command.
1.5. WEBDRIVE
WebDrive is a Windows WebDAV utility that allows you to map a network drive letter
to a WebDAV service. This makes it convenient for a Windows user to gain access
to their WebDAV folder information in much the same way they can access a
network drive. For more information, visit the WebDrive
Homepage: http://www.southrivertech.com/.
1.5.1.
SUPPORTED PLATFORMS
Windows ME/2000/XP
1.5.2.
INSTALLATION
PAGE 319
WebDav Clients
Give the site an identifiable name and then map the WebDAV URL to the one
specified in the Participant connectivity documentation. Set the server type to
WebDAV, select the drive letter to a desirable letter, and enter your User ID and
Password. Once this is finished, click on the Connect button. Test the connection
by examining the contents of the mapped drive.
1.5.3.
Once installed, you can access formulary or provider information from Surescripts
WebDAV server by browsing the mapped drive with a Windows browser or by
accessing it via a DOS window. WebDrive will manage authentication, so you do
not need to re-enter your Participant User ID and password. You can download
files by using cut and paste techniques, or by using the copy command from a DOS
window.
PAGE 320
WebDav Clients
PAGE 321
WebDav Clients
1.6. CAQH
Formulary list naming in WebDAV is slightly different for CAQH files compared to the
example in Section 8.8.3 Formulary and Benefit File Naming and Structure.
In the example below CAQH formulary list naming is illustrated.
CAQH
COV
QLSTNATIONAL_20050301_20050415
QLANBLUSELCT_20050301_20050415
RLWPMISSOURI_20050301_20050420
FSL
STNATIONAL_20050301_20050415
ANBLUSELCT_20050301_20050317
WPMISSOUR_20050301_20050420
In the CAQH formulary implementation only Formulary and Coverage lists will be
created.
For Coverage lists, the first 2 bytes of the file name represent the coverage type (e.g.
QL=Quantity Limit). The next 10 bytes represent the Formulary ID value in the
formulary file detail header (FHD). This 10 byte value is defined such that the first 2
bytes represent the publisher name (e.g. AN=Anthem) and the remaining 8 bytes
represent the formulary name. Each publisher will have its own unique 2 byte
identifier. CAQH publishers also provide a 35 character formulary name in the
Formulary Name field of the formulary file detail header (FHD) record.
PAGE 322
WebDav Clients
PAGE 323
APPENDIX B:
Surescripts supports two methods for file transfer: CONNECT:Direct and Secure FTP.
1.2. CONNECT:DIRECT
Connect:Direct is a peer-to-peer file-based integration middleware solution that is
optimized for assured delivery, high volume and secure data exchange. PBM
participants currently use Connect:Direct to send formulary and benefit files
(Formulary and Benefit Data Load) and member directory files (ID Load) to
Surescripts.
This section provides guidelines for Participants on how to setup, configure, and use
Connect:Direct to exchange files with Surescripts.
Surescripts and the Participant need to provide the following network information to
each other in order to set up the Connect:Direct connection between their
environments:
PAGE 324
The syntax of the to portion of the copy statement must be compatible with
Surescripts host and file type. Surescripts provides this portion of the copy
statement to the Participant. For more information, refer to the Connect:Direct
UNIX Copy Statement and Connect:Direct UNIX Run Task Statement sections in
the Connect:Direct Process Guide, Volume 3, located
at https://support.sterlingcommerce.com/content/documentation/ConnectDirect/CD
_ProcessGuides/CDProcessStatementsGuide.pdf
Submit proc1 process
snode=surescripts.node.name
snodeid=(username,password)
step1 copy from
(file=participant.data.filename pnode)
compress ext
to
(file=surescripts.filename
disp=(new)
sysopts=:strip.blanks=NO: snode)
eif
pend;
process
snode=participant.node.name
snodeid=(username,password)
step01 copy from
to
(file=surescripts.filename pnode)
(dsn=participant.filename
dcb=(RECFM=FB,LRECL=137)
disp=(new,keep/catalog,delete)
snode)
pend;
PAGE 325
PAGE 326
PAGE 327
APPENDIX C:
Dynamic Delimiters
DYNAMIC DELIMITERS
This section contains a full list of characters that are acceptable to use as delimiters.
Char
(bel)
(ht)
(nl)
(vt)
(cr)
(np)
(fs)
(gs)
(rs)
(us)
!
"
%
&
'
(
)
Dec
7
9
10
11
13
12
28
29
30
31
33
34
37
38
39
40
41
Oct
0007
0011
0012
0013
0015
0014
0034
0035
0036
0037
0041
0042
0045
0046
0047
0050
0051
Hex
0x07
0x09
0x0a
0x0b
0x0d
0x0c
0x1c
0x1d
0x1e
0x1f
0x21
0x22
0x25
0x26
0x27
0x28
0x29
*
+
,
.
/
:
;
<
=
>
?
@
[
\
]
^
_
`
{
|
}
~
42
43
44
45
46
47
58
59
60
61
62
63
64
91
92
93
94
95
96
123
124
125
126
0052
0053
0054
0055
0056
0057
0072
0073
0074
0075
0076
0077
0100
0133
0134
0135
0136
0137
0140
0173
0174
0175
0176
0x2a
0x2b
0x2c
0x2d
0x2e
0x2f
0x3a
0x3b
0x3c
0x3d
0x3e
0x3f
0x40
0x5b
0x5c
0x5d
0x5e
0x5f
0x60
0x7b
0x7c
0x7d
0x7e
PAGE 328