Eligibility Verification API Documentation

Eligibility Verification

Verify eligibility for patients for over 400 payers (insurances).

Our current supported EDI version: 005010

Need help with some of our documentation? Feel free to contact our support team, and one of our support team members will be happy to assist you.

Smart JSON 270 Request to Smart JSON 271 Response

Verify eligibility using the Smart JSON 270 request and Smart JSON 271 response. Recommended unless you need specific requirements that the Smart JSON may not support.

post https://api-edi.splinxtechnologies.com/v1/edi/eligibility-verification/smart270-to-smart271

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Request fields

Field

Description

MemberProfile required

MemberProfile represents each member, which is the subscriber or dependent. Use class MemberProfile for reference.

TransactionDate required

string<mm/dd/yy> represents the date at which the transaction is sent.

ProviderFirstName optional

string<1-35 characters> represents the provider's first name who is verifying the patient's eligibility. Only send if the provider is verifying the eligibility.

ProviderLastNameOrOrganizationName required

string<1-60 characters> represents the provider's last name or the organization's name, depending on which entity is verifying the patient eligibility.

OrganizationTypeCode required

string represents the type of entity that is making the request. Use table EDI Entity Identifier Codes for reference.

OrganizationIdentifierType required

string represents the type of identification for the entity that is making the request. Use table EDI Identification Code Identifiers for reference.

OrganizationIdentifier required

string<2-80 characters> represents the identification for the entity that is making the request.

PayerId required

string<2-80 characters> represents the id of the payer or insurance. Use table Health Care Eligibility Verification Payers for reference.

ServiceTypeCodes optional

List<string> represents any service codes to send in the request that may be used for more accurate verification of eligibility. If left empty, default value is 30. Use table EDI Service Type Codes for reference.

Response fields

Field

Description

IsRejected

boolean represents whether the request was rejected.

RejectReason

List<string> represents the reasons for rejection.

EligibilityOrBenefitSourceInformation

List<EligibilityOrBenefitSource> represents the party that verifies the eligibility. Use class EligibilityOrBenefitSource for reference.

Subscriber

MemberProfile represents the subscriber. Use class MemberProfile for reference.

Dependent

MemberProfile represents the dependent. Use class MemberProfile for reference.

SubscriberEligibilityOrBenefitInformation

List<EligibilityOrBenefitInformation> represents the subscriber's eligibility or benefit information. Use class EligibilityOrBenefitInformation for reference.

DependentEligibilityOrBenefitInformation

List<EligibilityOrBenefitInformation> represents the dependent's eligibility or benefit information. Use class EligibilityOrBenefitInformation for reference.

Sample request

Smart JSON 270 Copy

{
  "MemberProfile": {
    "FirstName": "JOHN",
    "LastName": "SMITH",
    "BirthDate": "05/19/1963",
    "StreetAddress": "",
    "City": "",
    "State": "",
    "ZipCode": "",
    "InsuredId": "",
    "SSN": "",
    "TraceReferenceId": "93175-012547",
    "EligibilityDate": "08/01/2023"
  },
  "TransactionDate": "05/01/2022",
  "ProviderLastNameOrOrganizationName": "Splinx Technologies",
  "OrganizationTypeCode": "2B",
  "OrganizationIdentifierType": "XX",
  "OrganizationIdentifier": "1234567890",
  "PayerId": "A1448",
  "ServiceTypeCodes": [
    "30"
  ]
}

Sample response

Smart JSON 271 Copy

{
  "IsRejected": false,
  "EligibilityOrBenefitSourceInformation": [
    {
      "EligibilityOrBenefitSourceType": "Payer",
      "EligibilityOrBenefitSourceName": "ABC COMPANY"
    }
  ],
  "Subscriber": {
    "FirstName": "JOHN",
    "LastName": "SMITH",
    "BirthDate": "05/19/1963",
    "StreetAddress": "15197 BROADWAY AVENUE",
    "City": "KANSAS CITY",
    "State": "MO",
    "ZipCode": "64108",
    "InsuredId": "123456789",
    "TraceReferenceId": "93175-012547"
  },
  "SubscriberEligibilityOrBenefitInformation": [
    {
      "EligibilityOrBenefitInformationDescription": "Active Coverage",
      "ServiceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "PlanCoverageDescription": "GOLD 123 PLAN",
      "EligibilityOrBenefitDates": [
        {
          "EligibilityOrBenefitDateQualifier": "Plan Begin",
          "EligibilityOrBenefitDateTime": "01/01/2006"
        }
      ]
    },
    {
      "EligibilityOrBenefitInformationDescription": "Primary Care Provider",
      "BenefitRelatedEntityNames": [
        {
          "EntityDescription": "Primary Care Provider",
          "Name": "JONES MARCUS"
        }
      ]
    },
    {
      "EligibilityOrBenefitInformationDescription": "Active Coverage",
      "ServiceTypes": [
        "Medical Care",
        "Chiropractic",
        "Dental Care",
        "Hospital",
        "Emergency Services",
        "Pharmacy",
        "Professional (Physician) Visit – Office",
        "Vision (Optometry)",
        "Mental Health",
        "Urgent Care"
      ]
    },
    {
      "EligibilityOrBenefitInformationDescription": "Co-Payment",
      "ServiceTypes": [
        "Medical Care",
        "Chiropractic",
        "Dental Care",
        "Hospital",
        "Emergency Services",
        "Pharmacy",
        "Professional (Physician) Visit – Office",
        "Vision (Optometry)",
        "Mental Health",
        "Urgent Care"
      ],
      "InsuranceTypeDescription": "Health Maintenance Organization (HMO)",
      "PlanCoverageDescription": "GOLD 123 PLAN",
      "CoveredAmount": "10",
      "TimePeriodQualifier": "Visit",
      "InNetwork": "Yes"
    },
    {
      "EligibilityOrBenefitInformationDescription": "Co-Payment",
      "ServiceTypes": [
        "Medical Care",
        "Chiropractic",
        "Dental Care",
        "Hospital",
        "Emergency Services",
        "Pharmacy",
        "Professional (Physician) Visit – Office",
        "Vision (Optometry)",
        "Mental Health",
        "Urgent Care"
      ],
      "InsuranceTypeDescription": "Health Maintenance Organization (HMO)",
      "PlanCoverageDescription": "GOLD 123 PLAN",
      "CoveredAmount": "30",
      "TimePeriodQualifier": "Visit",
      "InNetwork": "No"
    }
  ]
}

Smart JSON 270 Request to JSON 271 Response

Verify eligibility using the Smart JSON 270 request and JSON 271 response. Recommended if a specialized response is needed.

post https://api-edi.splinxtechnologies.com/v1/edi/eligibility-verification/smart270-to-json271

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Request fields

Field

Description

MemberProfile required

MemberProfile represents each member, which is the subscriber or dependent. Use class MemberProfile for reference.

TransactionDate required

string<mm/dd/yy> represents the date at which the transaction is sent.

ProviderFirstName optional

string<1-35 characters> represents the provider's first name who is verifying the patient's eligibility. Only send if the provider is verifying the eligibility.

ProviderLastNameOrOrganizationName required

string<1-60 characters> represents the provider's last name or the organization's name, depending on which entity is verifying the patient eligibility.

OrganizationTypeCode required

string represents the type of entity that is making the request. Use table EDI Entity Identifier Codes for reference.

OrganizationIdentifierType required

string represents the type of identification for the entity that is making the request. Use table EDI Identification Code Identifiers for reference.

OrganizationIdentifier required

string<2-80 characters> represents the identification for the entity that is making the request.

PayerId required

string<2-80 characters> represents the id of the payer or insurance. Use table Health Care Eligibility Verification Payers for reference.

ServiceTypeCodes optional

Sample request

Smart JSON 270 Copy

{
  "MemberProfile": {
    "FirstName": "JOHN",
    "LastName": "SMITH",
    "BirthDate": "05/19/1963",
    "StreetAddress": "",
    "City": "",
    "State": "",
    "ZipCode": "",
    "InsuredId": "",
    "SSN": "",
    "TraceReferenceId": "93175-012547",
    "EligibilityDate": "08/01/2023"
  },
  "TransactionDate": "05/01/2022",
  "ProviderLastNameOrOrganizationName": "Splinx Technologies",
  "OrganizationTypeCode": "2B",
  "OrganizationIdentifierType": "XX",
  "OrganizationIdentifier": "1234567890",
  "PayerId": "A1448",
  "ServiceTypeCodes": [
    "30"
  ]
}

Sample response

EDI 271 JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X279A1"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "271",
            "ST_02_TransactionSetControlNumber_AN": "4321",
            "ST_03_ImplementationConventionReference_AN": "005010X279A1"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0022",
            "BHT_02_TransactionSetPurposeCode_ID": "11",
            "BHT_03_ReferenceIdentification_AN": "10001234",
            "BHT_04_Date_DT": "20060501",
            "BHT_05_Time_TM": "1319",
            "BHT_06_TransactionTypeCode_ID": null
          },
          "InformationSourceLevel_Loop_2000A": [
            {
              "InformationSourceLevel": {
                "HL_01_HierarchicalIDNumber_AN": "1",
                "HL_02_HierarchicalParentIDNumber_AN": null,
                "HL_03_HierarchicalLevelCode_ID": "20",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "RequestValidation": null,
              "InformationSourceName_Loop_2100A": {
                "InformationSourceName": {
                  "NM1_01_EntityIdentifierCode_ID": "PR",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "ABC COMPANY",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "PI",
                  "NM1_09_IdentificationCode_AN": "842610001",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "InformationSourceContactInformation": null,
                "RequestValidation": null
              }
            }
          ],
          "InformationReceiverLevel_Loop_2000B": [
            {
              "InformationReceiverLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "21",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "InformationReceiverName_Loop_2100B": {
                "InformationReceiverName": {
                  "NM1_01_EntityIdentifierCode_ID": "1P",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "BONE AND JOINT CLINIC",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "SV",
                  "NM1_09_IdentificationCode_AN": "2000035",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "InformationReceiverAdditionalIdentification": null,
                "InformationReceiverAddress": null,
                "InformationReceiverCityStateZipCode": null,
                "InformationReceiverRequestValidation": null,
                "InformationReceiverProviderInformation": null
              }
            }
          ],
          "SubscriberLevel_Loop_2000C": [
            {
              "SubscriberLevel": {
                "HL_01_HierarchicalIDNumber_AN": "3",
                "HL_02_HierarchicalParentIDNumber_AN": "2",
                "HL_03_HierarchicalLevelCode_ID": "22",
                "HL_04_HierarchicalChildCode_ID": "0"
              },
              "SubscriberTraceNumber": [
                {
                  "TRN_01_TraceTypeCode_ID": "2",
                  "TRN_02_ReferenceIdentification_AN": "93175-012547",
                  "TRN_03_OriginatingCompanyIdentifier_AN": "9877281234",
                  "TRN_04_ReferenceIdentification_AN": null
                }
              ],
              "SubscriberName_Loop_2100C": {
                "SubscriberName": {
                  "NM1_01_EntityIdentifierCode_ID": "IL",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "JOHN",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "MI",
                  "NM1_09_IdentificationCode_AN": "123456789",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "SubscriberAdditionalIdentification": null,
                "SubscriberAddress": {
                  "N3_01_AddressInformation_AN": "15197 BROADWAY AVENUE",
                  "N3_02_AddressInformation_AN": "APT 215"
                },
                "SubscriberCityStateZipCode": {
                  "N4_01_CityName_AN": "KANSAS CITY",
                  "N4_02_StateOrProvinceCode_ID": "MO",
                  "N4_03_PostalCode_ID": "64108",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "SubscriberRequestValidation": null,
                "ProviderInformation": null,
                "SubscriberDemographicInformation": {
                  "DMG_01_DateTimePeriodFormatQualifier_ID": "D8",
                  "DMG_02_DateTimePeriod_AN": "19630519",
                  "DMG_03_GenderCode_ID": "M",
                  "DMG_04_MaritalStatusCode_ID": null,
                  "DMG_05_CompositeRaceOrEthnicityInformation": null,
                  "DMG_06_CitizenshipStatusCode_ID": null,
                  "DMG_07_CountryCode_ID": null,
                  "DMG_08_BasisOfVerificationCode_ID": null,
                  "DMG_09_Quantity_R": null,
                  "DMG_10_CodeListQualifierCode_ID": null,
                  "DMG_11_IndustryCode_AN": null
                },
                "SubscriberRelationship": null,
                "SubscriberHealthCareDiagnosisCode": null,
                "SubscriberDate": [
                  {
                    "DTP_01_DateTimeQualifier_ID": "346",
                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                    "DTP_03_DateTimePeriod_AN": "20060101"
                  }
                ],
                "SubscriberMilitaryPersonnelInformation": null,
                "SubscriberEligibilityOrBenefitInformation_Loop_2110C": [
                  {
                    "SubscriberEligibilityOrBenefitInformation": {
                      "EB_01_EligibiityOrBenefitInformationCode_ID": "1",
                      "EB_02_CoverageLevelCode_ID": null,
                      "EB_03_ServiceTypeCode_ID": [
                        "30"
                      ],
                      "EB_04_InsuranceTypeCode_ID": null,
                      "EB_05_PlanCoverageDescription_AN": "GOLD 123 PLAN",
                      "EB_06_TimePeriodQualifier_ID": null,
                      "EB_07_MonetaryAmount_R": null,
                      "EB_08_PercentageAsDecimal_R": null,
                      "EB_09_QuantityQualifier_ID": null,
                      "EB_10_Quantity_R": null,
                      "EB_11_YesNoConditionOrResponseCode_ID": null,
                      "EB_12_YesNoConditionOrResponseCode_ID": null,
                      "EB_13_CompositeMedicalProcedureIdentifier": null,
                      "EB_14_CompositeDiagnosisCodePointer": null
                    },
                    "HealthCareServicesDelivery": null,
                    "SubscriberAdditionalIdentification": null,
                    "SubscribeEligibilityBenefitDate": null,
                    "SubscriberRequestValidation": null,
                    "MessageText": null,
                    "SubscriberEligibilityOrBenefitAdditionalInformation_Loop_2115C": [
                      {
                        "SubscriberEligibilityOrBenefitAdditionalInformation": null
                      }
                    ],
                    "LoopHeader": null,
                    "SubscriberBenefitRelatedEntityName_Loop_2120C": [
                      {
                        "SubscriberBenefitRelatedEntityName": null,
                        "SubscriberBenefitRelatedEntityAddress": null,
                        "SubscriberBenefitRelatedEntityCityStateZipCode": null,
                        "SubscriberBenefitRelatedEntityContactInformation": null,
                        "SubscriberBenefitRelatedProviderInformation": null
                      }
                    ],
                    "LoopTrailer": null
                  },
                  {
                    "SubscriberEligibilityOrBenefitInformation": {
                      "EB_01_EligibiityOrBenefitInformationCode_ID": "L",
                      "EB_02_CoverageLevelCode_ID": null,
                      "EB_03_ServiceTypeCode_ID": null,
                      "EB_04_InsuranceTypeCode_ID": null,
                      "EB_05_PlanCoverageDescription_AN": null,
                      "EB_06_TimePeriodQualifier_ID": null,
                      "EB_07_MonetaryAmount_R": null,
                      "EB_08_PercentageAsDecimal_R": null,
                      "EB_09_QuantityQualifier_ID": null,
                      "EB_10_Quantity_R": null,
                      "EB_11_YesNoConditionOrResponseCode_ID": null,
                      "EB_12_YesNoConditionOrResponseCode_ID": null,
                      "EB_13_CompositeMedicalProcedureIdentifier": null,
                      "EB_14_CompositeDiagnosisCodePointer": null
                    },
                    "HealthCareServicesDelivery": null,
                    "SubscriberAdditionalIdentification": null,
                    "SubscribeEligibilityBenefitDate": null,
                    "SubscriberRequestValidation": null,
                    "MessageText": null,
                    "SubscriberEligibilityOrBenefitAdditionalInformation_Loop_2115C": [
                      {
                        "SubscriberEligibilityOrBenefitAdditionalInformation": null
                      }
                    ],
                    "LoopHeader": {
                      "LS_01_LoopIdentifierCode_AN": "2120"
                    },
                    "SubscriberBenefitRelatedEntityName_Loop_2120C": [
                      {
                        "SubscriberBenefitRelatedEntityName": {
                          "NM1_01_EntityIdentifierCode_ID": "P3",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "JONES",
                          "NM1_04_NameFirst_AN": "MARCUS",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "SV",
                          "NM1_09_IdentificationCode_AN": "0202034",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        },
                        "SubscriberBenefitRelatedEntityAddress": null,
                        "SubscriberBenefitRelatedEntityCityStateZipCode": null,
                        "SubscriberBenefitRelatedEntityContactInformation": null,
                        "SubscriberBenefitRelatedProviderInformation": null
                      }
                    ],
                    "LoopTrailer": {
                      "LE_01_LoopIdentifierCode_AN": "2120"
                    }
                  },
                  {
                    "SubscriberEligibilityOrBenefitInformation": {
                      "EB_01_EligibiityOrBenefitInformationCode_ID": "1",
                      "EB_02_CoverageLevelCode_ID": null,
                      "EB_03_ServiceTypeCode_ID": [
                        "1",
                        "33",
                        "35",
                        "47",
                        "86",
                        "88",
                        "98",
                        "AL",
                        "MH",
                        "UC"
                      ],
                      "EB_04_InsuranceTypeCode_ID": null,
                      "EB_05_PlanCoverageDescription_AN": null,
                      "EB_06_TimePeriodQualifier_ID": null,
                      "EB_07_MonetaryAmount_R": null,
                      "EB_08_PercentageAsDecimal_R": null,
                      "EB_09_QuantityQualifier_ID": null,
                      "EB_10_Quantity_R": null,
                      "EB_11_YesNoConditionOrResponseCode_ID": null,
                      "EB_12_YesNoConditionOrResponseCode_ID": null,
                      "EB_13_CompositeMedicalProcedureIdentifier": null,
                      "EB_14_CompositeDiagnosisCodePointer": null
                    },
                    "HealthCareServicesDelivery": null,
                    "SubscriberAdditionalIdentification": null,
                    "SubscribeEligibilityBenefitDate": null,
                    "SubscriberRequestValidation": null,
                    "MessageText": null,
                    "SubscriberEligibilityOrBenefitAdditionalInformation_Loop_2115C": [
                      {
                        "SubscriberEligibilityOrBenefitAdditionalInformation": null
                      }
                    ],
                    "LoopHeader": null,
                    "SubscriberBenefitRelatedEntityName_Loop_2120C": [
                      {
                        "SubscriberBenefitRelatedEntityName": null,
                        "SubscriberBenefitRelatedEntityAddress": null,
                        "SubscriberBenefitRelatedEntityCityStateZipCode": null,
                        "SubscriberBenefitRelatedEntityContactInformation": null,
                        "SubscriberBenefitRelatedProviderInformation": null
                      }
                    ],
                    "LoopTrailer": null
                  },
                  {
                    "SubscriberEligibilityOrBenefitInformation": {
                      "EB_01_EligibiityOrBenefitInformationCode_ID": "B",
                      "EB_02_CoverageLevelCode_ID": null,
                      "EB_03_ServiceTypeCode_ID": [
                        "1",
                        "33",
                        "35",
                        "47",
                        "86",
                        "88",
                        "98",
                        "AL",
                        "MH",
                        "UC"
                      ],
                      "EB_04_InsuranceTypeCode_ID": "HM",
                      "EB_05_PlanCoverageDescription_AN": "GOLD 123 PLAN",
                      "EB_06_TimePeriodQualifier_ID": "27",
                      "EB_07_MonetaryAmount_R": "10",
                      "EB_08_PercentageAsDecimal_R": null,
                      "EB_09_QuantityQualifier_ID": null,
                      "EB_10_Quantity_R": null,
                      "EB_11_YesNoConditionOrResponseCode_ID": null,
                      "EB_12_YesNoConditionOrResponseCode_ID": "Y",
                      "EB_13_CompositeMedicalProcedureIdentifier": null,
                      "EB_14_CompositeDiagnosisCodePointer": null
                    },
                    "HealthCareServicesDelivery": null,
                    "SubscriberAdditionalIdentification": null,
                    "SubscribeEligibilityBenefitDate": null,
                    "SubscriberRequestValidation": null,
                    "MessageText": null,
                    "SubscriberEligibilityOrBenefitAdditionalInformation_Loop_2115C": [
                      {
                        "SubscriberEligibilityOrBenefitAdditionalInformation": null
                      }
                    ],
                    "LoopHeader": null,
                    "SubscriberBenefitRelatedEntityName_Loop_2120C": [
                      {
                        "SubscriberBenefitRelatedEntityName": null,
                        "SubscriberBenefitRelatedEntityAddress": null,
                        "SubscriberBenefitRelatedEntityCityStateZipCode": null,
                        "SubscriberBenefitRelatedEntityContactInformation": null,
                        "SubscriberBenefitRelatedProviderInformation": null
                      }
                    ],
                    "LoopTrailer": null
                  },
                  {
                    "SubscriberEligibilityOrBenefitInformation": {
                      "EB_01_EligibiityOrBenefitInformationCode_ID": "B",
                      "EB_02_CoverageLevelCode_ID": null,
                      "EB_03_ServiceTypeCode_ID": [
                        "1",
                        "33",
                        "35",
                        "47",
                        "86",
                        "88",
                        "98",
                        "AL",
                        "MH",
                        "UC"
                      ],
                      "EB_04_InsuranceTypeCode_ID": "HM",
                      "EB_05_PlanCoverageDescription_AN": "GOLD 123 PLAN",
                      "EB_06_TimePeriodQualifier_ID": "27",
                      "EB_07_MonetaryAmount_R": "30",
                      "EB_08_PercentageAsDecimal_R": null,
                      "EB_09_QuantityQualifier_ID": null,
                      "EB_10_Quantity_R": null,
                      "EB_11_YesNoConditionOrResponseCode_ID": null,
                      "EB_12_YesNoConditionOrResponseCode_ID": "N",
                      "EB_13_CompositeMedicalProcedureIdentifier": null,
                      "EB_14_CompositeDiagnosisCodePointer": null
                    },
                    "HealthCareServicesDelivery": null,
                    "SubscriberAdditionalIdentification": null,
                    "SubscribeEligibilityBenefitDate": null,
                    "SubscriberRequestValidation": null,
                    "MessageText": null,
                    "SubscriberEligibilityOrBenefitAdditionalInformation_Loop_2115C": [
                      {
                        "SubscriberEligibilityOrBenefitAdditionalInformation": null
                      }
                    ],
                    "LoopHeader": null,
                    "SubscriberBenefitRelatedEntityName_Loop_2120C": [
                      {
                        "SubscriberBenefitRelatedEntityName": null,
                        "SubscriberBenefitRelatedEntityAddress": null,
                        "SubscriberBenefitRelatedEntityCityStateZipCode": null,
                        "SubscriberBenefitRelatedEntityContactInformation": null,
                        "SubscriberBenefitRelatedProviderInformation": null
                      }
                    ],
                    "LoopTrailer": null
                  }
                ]
              }
            }
          ],
          "DependentLevel_Loop_2000D": [
            {
              "DependentLevel": null,
              "DependentTraceNumber": null,
              "DependentName_Loop_2100D": {
                "DependentName": null,
                "DependentAdditionalIdentification": null,
                "DependentAddress": null,
                "DependentCityStateZipCode": null,
                "DependentRequestValidation": null,
                "ProviderInformation": null,
                "DependentDemographicInformation": null,
                "DependentRelationship": null,
                "DependentHealthCareDiagnosisCode": null,
                "DependentDate": null,
                "DependentMilitaryPersonnelInformation": null,
                "DependentEligibilityOrBenefitInformation_Loop_2110D": [
                  {
                    "DependentEligibilityOrBenefitInformation": null,
                    "HealthCareServicesDelivery": null,
                    "DependentAdditionalIdentification": null,
                    "DependentEligibilityBenefitDate": null,
                    "DependentRequestValidation": null,
                    "MessageText": null,
                    "DependentEligibilityOrBenefitAdditionalInformation_Loop_2115D": [
                      {
                        "DependentEligibilityOrBenefitAdditionalInformation": null
                      }
                    ],
                    "LoopHeader": null,
                    "DependentBenefitRelatedEntityName_Loop_2120D": [
                      {
                        "DependentBenefitRelatedEntityName": null,
                        "DependentBenefitRelatedEntityAddress": null,
                        "DependentBenefitRelatedEntityCityStateZipCode": null,
                        "DependentBenefitRelatedEntityContactInformation": null,
                        "DependentBenefitRelatedEntityProviderInformation": null
                      }
                    ],
                    "LoopTrailer": null
                  }
                ]
              }
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "22",
            "SE_02_TransactionSetControlNumber_AN": "4321"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "2",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "161130044"
  }
}

Smart JSON 270 Request to EDI 271 Response

Verify eligibility using the Smart JSON 270 request and EDI 271 response. Recommended if an EDI 271 message response is needed.

post https://api-edi.splinxtechnologies.com/v1/edi/eligibility-verification/smart270-to-edi271

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Request fields

Field

Description

MemberProfile required

MemberProfile represents each member, which is the subscriber or dependent. Use class MemberProfile for reference.

TransactionDate required

string<mm/dd/yy> represents the date at which the transaction is sent.

ProviderFirstName optional

string<1-35 characters> represents the provider's first name who is verifying the patient's eligibility. Only send if the provider is verifying the eligibility.

ProviderLastNameOrOrganizationName required

string<1-60 characters> represents the provider's last name or the organization's name, depending on which entity is verifying the patient eligibility.

OrganizationTypeCode required

string represents the type of entity that is making the request. Use table EDI Entity Identifier Codes for reference.

OrganizationIdentifierType required

string represents the type of identification for the entity that is making the request. Use table EDI Identification Code Identifiers for reference.

OrganizationIdentifier required

string<2-80 characters> represents the identification for the entity that is making the request.

PayerId required

string<2-80 characters> represents the id of the payer or insurance. Use table Health Care Eligibility Verification Payers for reference.

ServiceTypeCodes optional

Sample request

Smart JSON 270 Copy

{
  "MemberProfile": {
    "FirstName": "JOHN",
    "LastName": "SMITH",
    "BirthDate": "05/19/1963",
    "StreetAddress": "",
    "City": "",
    "State": "",
    "ZipCode": "",
    "InsuredId": "",
    "SSN": "",
    "TraceReferenceId": "93175-012547",
    "EligibilityDate": "08/01/2023"
  },
  "TransactionDate": "05/01/2022",
  "ProviderLastNameOrOrganizationName": "Splinx Technologies",
  "OrganizationTypeCode": "2B",
  "OrganizationIdentifierType": "XX",
  "OrganizationIdentifier": "1234567890",
  "PayerId": "A1448",
  "ServiceTypeCodes": [
    "30"
  ]
}

Sample response

EDI 271 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X279A1~ST*271*4321*005010X279A1~BHT*0022*11*10001234*20060501*1319~HL*1**20*1~NM1*PR*2*ABC COMPANY*****PI*842610001~HL*2*1*21*1~NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~HL*3*2*22*0~TRN*2*93175-012547*9877281234~NM1*IL*1*SMITH*JOHN****MI*123456789~N3*15197 BROADWAY AVENUE*APT 215~N4*KANSAS CITY*MO*64108~DMG*D8*19630519*M~DTP*346*D8*20060101~EB*1**30**GOLD 123 PLAN~EB*L~LS*2120~NM1*P3*1*JONES*MARCUS****SV*0202034~LE*2120~EB*1**1^33^35^47^86^88^98^AL^MH^UC~EB*B**1^33^35^47^86^88^98^AL^MH^UC*HM*GOLD 123 PLAN*27*10*****Y~EB*B**1^33^35^47^86^88^98^AL^MH^UC*HM*GOLD 123 PLAN*27*30*****N~SE*22*4321~GE*2*1~IEA*1*161130044~

EligibilityOrBenefitSource fields

Field

Description

EligibilityOrBenefitSourceType

string

EligibilityOrBenefitSourceName

string

MemberProfile fields (request)

Field

Description

FirstName required

string<1-35 characters>

LastName required

string<1-60 characters>

BirthDate required

string<mm/dd/yy>

StreetAddress optional

string<1-55 characters>

City optional

string<2-30 characters>

State optional

string<2 characters>

ZipCode optional

string<5-15 characters>

InsuredId optional

string<2-80 characters> represents the subscriber insurance identification.

SSN optional

string

TraceReferenceId optional

string<1-50 characters> represents what value will be sent back in the response.

EligibilityDate required

string<mm/dd/yy>

MemberProfile fields (response)

Field

Description

FirstName

string<1-35 characters>

LastName

string<1-60 characters>

BirthDate

string<mm/dd/yy>

StreetAddress

string<1-55 characters>

City

string<2-30 characters>

State

string<2 characters>

ZipCode

string<5-15 characters>

InsuredId

string<2-80 characters> represents the subscriber insurance identification.

SSN

string

TraceReferenceId

string<1-50 characters> represents a value that was sent in an EDI 270 request.

ResponseTraceReferenceId

string<1-50 characters> represents what value will be sent back in the response.

EligibilityOrBenefitInformation fields

Field

Description

EligibilityOrBenefitInformationDescription

string represents the description of the eligibility or benefit.

CoverageLevelDescription

string represents the type of coverage for the eligibility or benefit.

InsuranceTypeDescription

string

PlanCoverageDescription

string

EligibilityOrBenefitDates

List<EligibilityOrBenefitDates> represents the dates for the eligibility or benefit. Use class EligibilityOrBenefitDates for reference.

CoveredAmount

string

BenefitPercent

string represents the Co-Insurance patient's portion of responsibility.

TimePeriodQualifier

string represents the time period for the given insurance coverage.

BenefitRelatedEntityNames

List<BenefitRelatedEntityNames> represents any entities that relate to the given eligibility or benefit. Use class BenefitRelatedEntityNames for reference.

BenefitQuantityQualifier

string represents a given quantity type for the eligibility or benefit.

BenefitQuantity

string represents a given quantity for the eligibility or benefit.

AuthorizationRequired

string

InNetwork

string represents whether the coverage is in network or not.

EligibilityOrBenefitDates fields

Field

Description

EligibilityOrBenefitDateQualifier

string represents information on the date given.

EligibilityOrBenefitDateTime

string

BenefitRelatedEntityNames fields

Field

Description

EntityDescription

string represents the description of the entity given.

Name

string

EDI Entity Identifier Codes Table

Name

Value

Contracted Service Provider

13 Preferred Provider Organization (PPO)

II

Provider

1P

Third-Party Administrator

2B

Employer

36 Other Physician

73 Hospital

80 Facility

FA

Gateway Provider

GP

Independent Physicians Association (IPA)

I3

Insured or Subscriber

IL

Legal Representative

LR

Original Carrier

OC

Primary Care Provider

P3

Prior Insurance Carrier

P4

Plan Sponsor

P5

Payer

PR

Primary Payer

PRP

Secondary Payer

SEP

Tertiary Payer

TTP

Party Performaing Verification

VER

Vendor

VN

Organization Completing Configuration Change

VY

Utilization Management Organization

X3

EDI Identification Code Identifiers Table

Name

Value

Employer's Identification Number

24 Social Security Number

34 Federal Taxpayer's Identification Number

FI

Payor Identification

PI

Pharmacy Processor Number

PP

Service Provider Number

SV

Center for Medicare and Medicaid Services PlanID

XV

Center for Medicare and Medicaid Services National Provider Identification (NPI)

XX

Electronic Transmitter Identification Number (ETIN)

46 National Association of Insurance Commissioners (NAIC) Identification

NI

Health Care Eligibility Verification Payers

Name

Value

1199 National Benefit Fund

A1005

AARP-UnitedHealthcare Ins Co

A1006

ACS Benefit Services

A1007

Advantage by Bridgeway Health Solutions

A1008

Aetna Better Health California

A1009

Aetna Better Health Illinois

A1010

Aetna Better Health Kansas

A1011

Aetna Better Health Kentucky

A1012

Aetna Better Health Louisiana

A1013

Aetna Better Health Maryland

A1014

Aetna Better Health New Jersey

A1015

Aetna Better Health Pennsylvania

A1016

Aetna Better Health Texas

A1017

Aetna Better Health Texas CHIP

A1018

Aetna Health Plans (AHP)

A1019

Aetna Health Plans PPO

A1020

Aetna Senior Supplemental

A1021

Affinity Health Plan

A1022

Aflac

A1023

AHP of New Jersey, Parsippany

A1024

AHP of New Jersey, Purchase, NY

A1025

Alabama Blue Cross (Institutional)

A1026

Alabama Blue Shield (Professional)

A1027

Alabama Medicaid

A1028

Alabama Medicare

B1005

Alaska Medicaid

A1030

Alaska Medicare

B1005

Aliera Health Care

A1032

AllSavers Life Insurance Company

A1033

Allegiance Benefit Plan Management Inc

A1034

Altius Health Plans

A1035

Ameriben Solutions Inc.

A1036

American Medical Security (AMS)

A1037

American Postal Workers Union Health Plan

A1038

American Samoa Medicare

B1005

AmeriChoice - Community and State

A1040

AmeriGroup

A1041

Amerihealth Administrators

A1042

Amerihealth Caritas Florida

A1043

Amerihealth Caritas Louisiana

A1044

Amerihealth Mercy Health Plan

A1045

Arise Health Plan

A1046

Arizona Blue Cross Blue Shield

A1047

Arizona Medicaid (AHCCCS)

A1048

Arizona Medicare

B1005

Arizona Physicians IPA - Community and State

A1050

Arkansas Blue Cross Blue Shield

A1051

Arkansas Medicaid

A1052

Arkansas Medicare

B1005

Aultcare

A1054

Avmed

A1055

Banner University Family Care

A1056

BCBS Texas Medicaid Star CHIP

A1057

Better Health

A1058

Bind

A1059

Blue Cross Community Health Plans

A1060

Blue Cross Medicare Advantage

A1061

Boston Medical Center Health Plan

A1062

Braven Health

A1063

Bravo Health (Cigna Healthspring)

A1064

Bridgeway Arizona

A1065

Bright Healthcare

A1066

California Anthem Blue Cross

A1067

California Anthem Blue Cross Dental

A1068

California Blue Shield

A1069

California Medicaid (Medi-Cal)

A1070

California Medicare

B1005

CalOptima

A1072

Capital Administrators

A1073

Capital Blue Cross of Pennsylvania

A1074

Care 1st Health Plan Arizona

A1075

Carefirst Blue Cross Blue Shield District of Columbia

A1076

Caremore

A1077

Caresource Arkansas

A1078

Caresource Georgia

A1079

Caresource Humana

A1080

Caresource Indiana

A1081

Caresource Ohio

A1082

Caresource West Virginia

A1083

Cariten Healthcare

A1084

CeltiCare

A1085

Centene Health

A1086

Centivo

A1087

Central California Alliance for Health

A1088

CHAMPVA

A1089

CIGNA

A1090

CIP (Care Improvement Plus)

A1091

Clear Health Alliance

A1092

Clover Health

A1093

CMS (Medicare)

B1005

Colorado Anthem Blue Cross Blue Shield

A1094

Colorado Anthem Blue Cross Blue Shield Dental

A1095

Colorado Community Health Alliance

A1096

Colorado Medicaid

A1097

Colorado Medicare

B1005

Community First Health Plans

A1099

Community Health Choice

A1100

ConnectiCare

A1101

ConnectiCare Medicare

A1102

Connecticut Anthem Blue Cross Blue Shield

A1103

Connecticut Anthem Blue Cross Blue Shield Dental

A1104

Connecticut General Life

A1105

Connecticut Medicaid

A1106

Connecticut Medicare

B1005

CoreSource (IL, IN, MD, NC & PA)

A1108

Coventry Advantra Savings

A1109

Coventry Advantra (Texas, New Mexico and Arizona)

A1110

Coventry Cares

A1111

Coventry Cares Michigan

A1112

Coventry Health and Life (Nevada)

A1113

Coventry Health and Life (Oklahoma)

A1114

Coventry Health and Life (Tennessee)

A1115

Coventry Healthcare Federal

A1116

Coventry Healthcare Florida Vista Summit

A1117

Coventry Health Care Carelink

A1118

Coventry Health Care Carelink Medicaid

A1119

Coventry Health Care CareNet

A1120

Coventry Health Care Group Health Plan (GHP)

A1121

Coventry Health Care Health America/ Health Assurance of Pennsylvania (HAPA)

A1122

Coventry Health Care Inc (Promina)

A1123

Coventry Health Care of Carolinas/WellPath

A1124

Coventry Health Care of Delaware

A1125

Coventry Health Care of Florida

A1126

Coventry Health Care of Georgia

A1127

Coventry Health Care of Iowa

A1128

Coventry Health Care of Kansas (Kansas City & Wichita)

A1129

Coventry Health Care of Louisiana

A1130

Coventry Health Care of Nebraska

A1131

Coventry Health Care Southern Health Services

A1132

Coventry Health Care Texas (includes Coventry Advantra Freedom)

A1133

Coventry Health Care USA (HCUSA)

A1134

Coventry Health of Illinois/ Personal Care

A1135

Coventry MHNET Behavioral Health

A1136

Coventry Missouri

A1137

Coventry Nebraska Medicaid

A1138

Coventry One

A1139

Coventry University of Missouri

A1140

Dean Health

A1141

Definity Health

A1142

Delaware Blue Cross Blue Shield

A1143

Delaware Medicaid

A1144

Delaware Medicare

B1005

Definity Health

A1146

Deseret Mutual (DMBA)

A1147

District of Columbia Medicaid

A1148

District of Columbia Medicare

B1005

Emblem Health

A1150

Essence Healthcare

A1151

Evergreen Health Cooperative

A1152

Excellus Blue Cross Blue Shield New York

A1153

Fallon Community Health Plan

A1154

Federated Mutual Insurance Company

A1155

Federated States of Micronesia Medicare

B1005

Fidelis (CenterCare)

A1157

First Ameritas of NY

A1158

First Carolina Care

A1159

First Health Coventry Health Care National Network

A1160

First Health Mail Handlers Benefit Plan

A1161

Florida Blue Cross Blue Shield

A1162

Florida Health Care Plan

A1163

Florida Medicaid

A1164

Florida Medicare

B1005

Gateway Health Plan

A1166

Geisinger Health Plan

A1167

GEMcare

A1168

Georgia Anthem Blue Cross Blue Shield

A1169

Georgia Anthem Blue Cross Blue Shield Dental

A1170

Georgia Medicaid

A1171

Georgia Medicare

B1005

Golden Rule Insurance

A1173

Government Employees Health Association (GEHA)

A1174

Great West

A1175

Group Health Incorporated

A1176

Guam Medicare

B1005

Harken Health

A1178

Harmony Health Plan (Illinois & Indiana)

A1179

Harvard Pilgrim

A1180

Hawaii Blue Cross Blue Shield

A1181

Hawaii Medicaid

A1182

Hawaii Medicare

B1005

Health Alliance Plan

A1184

Health Choice of Arizona

A1185

Health First Health Plan

A1186

Health Net National

A1187

Health Net of California

A1188

Health Partners Pennsylvania

A1189

Health Tradition Health Plan

A1190

Healthcare Highways

A1191

HealthChoice

A1192

HealthChoice Dept of Corrections & Rehab

A1505

HealthEase

A1193

HealthEase Kids

A1194

HealthFirst of New York

A1195

Healthnow

A1196

HealthPartners of Minnesota

A1197

Healthplans Incorporated

A1198

Healthplus Michigan

A1199

Healthscope Benefits Administrators

A1200

Healthscope HSB

A1201

Healthsmart Benefit Solutions

A1202

Horizon New Jersey Health

A1203

Humana

A1204

Idaho Blue Cross

A1205

Idaho Blue Shield (Regence)

A1206

Idaho Medicaid

A1207

Idaho Medicare

B1005

Illinois Blue Cross Blue Shield

A1209

Illinois Medicaid

A1210

Illinois Medicare

B1005

Indiana Anthem Blue Cross Blue Shield

A1212

Indiana Anthem Blue Cross Blue Shield Dental

A1213

Indiana Medicaid

A1214

Indiana Medicare

B1005

Independent Health

A1216

Inland Empire Health Plan

A1217

Iowa Blue Cross Blue Shield

A1218

Iowa Medicaid

A1219

Iowa Medicare

B1005

Johns Hopkins Health Plan

A1221

Kaiser Foundation Colorado

A1222

Kaiser Foundation Health Plan Hawaii

A1223

Kaiser Foundation Health Plan Hawaii (DHMO Choice)

A1224

Kaiser Foundation Health Plan Washington

A1225

Kaiser Found'ation Northwest

A1226

Kaiser Foundation Mid Atlantic

A1227

Kaiser Foundation Ohio

A1228

Kaiser Permanente Georgia

A1229

Kaiser Permanente KPIC

A1230

Kaiser Permanente Northern CA

A1231

Kaiser Permanente Southern CA

A1232

Kansas Blue Cross Blue Shield

A1233

Kansas City Blue Cross Blue Shield

A1234

Kansas Medicaid

A1235

Kansas Medicare

B1005

Kentucky Anthem Blue Cross Blue Shield

A1237

Kentucky Anthem Blue Cross Blue Shield Dental

A1238

Kentucky Medicaid

A1239

Kentucky Medicare

B1005

Keystone Mercy

A1241

Lifewise Health Plan Oregon

A1242

Loomis Company

A1243

Louisiana Blue Cross Blue Shield

A1244

Louisiana Medicaid

A1245

Louisiana Medicare

B1005

Magellan Health Services

A1247

Magnacare

A1248

MAHP/MAMSI

A1249

Maine Anthem Blue Cross Blue Shield

A1250

Maine Anthem Blue Cross Blue Shield Dental

A1251

Maine Medicaid

A1252

Maine Medicare

B1005

March Vision Care

A1254

Marpai, Inc

A1255

Marshall Islands Medicare

B1005

Maryland Blue Cross Blue Shield (CareFirst)

A1257

Maryland Medicaid

A1258

Maryland Medicare

B1005

Maryland Physicians Care

A1260

Massachusetts Blue Cross Blue Shield

A1261

Massachusetts Medicaid

A1262

Massachusetts Medicare

B1005

McLaren Health Care

A1264

MDWise

A1265

Medica Health Plans

A1266

Medica Health Plan Solutions

A1267

Medica Health Care Plan - Florida

A1268

Medical Mutual of Ohio

A1269

Medigold Health Plans

A1270

Meridian Health Plan Illinois

A1271

Meridian Total, Meridian Complete, Illinois Complete, YouthCare and Ambetter

A1272

Meritain Health

A1273

MetroPlus Health Plan

A1274

Michigan Blue Cross Blue Shield

A1275

Michigan Medicaid

A1276

Michigan Medicare

B1005

Michild Michigan

A1278

Minnesota Blue Cross Blue Shield

A1279

Minnesota Blue Cross Blue Shield Blue Plus Medicaid

A1280

Minnesota Medicaid

A1281

Minnesota Medicare

B1005

Mississippi Blue Cross Blue Shield

A1283

Mississippi Medicaid

A1284

Mississippi Medicare

B1005

Missouri Anthem Blue Cross Blue Shield

A1286

Missouri Anthem Blue Cross Blue Shield Dental

A1287

Missouri (MO) Health Plan (Community & State)

A1288

Missouri Medicaid

A1289

Missouri Medicare

B1005

Moda Health

A1291

Molina Healthcare California

A1292

Molina Healthcare Florida

A1293

Molina Healthcare Idaho

A1294

Molina Healthcare Illinois

A1295

Molina Healthcare Michigan

A1296

Molina Healthcare New Mexico

A1297

Molina Healthcare Ohio

A1298

Molina Healthcare South Carolina

A1299

Molina Healthcare Texas

A1300

Molina Healthcare Utah

A1301

Molina Healthcare Washington

A1302

Molina Healthcare Wisconsin

A1303

Montana Blue Cross Blue Shield

A1304

Montana Medicaid

A1305

Montana Medicare

B1005

Mutual of Omaha

A1307

MVP Health Plan

A1308

National Association of Letter Carriers (NALC)

A1309

Nebraska Blue Cross Blue Shield

A1310

Nebraska Medicaid

A1311

Nebraska Medicare

B1005

Neighborhood Health Plan

A1313

Network Health

A1314

Nevada Anthem Blue Cross Blue Shield

A1315

Nevada Anthem Blue Cross Blue Shield Dental

A1316

Nevada Medicaid

A1317

Nevada Medicare

B1005

New Hampshire Anthem Blue Cross Blue Shield

A1319

New Hampshire Anthem Blue Cross Blue Shield Dental

A1320

New Hampshire Medicaid

A1321

New Hampshire Medicare

B1005

New Jersey Blue Cross Blue Shield (Horizon)

A1323

New Jersey Medicaid

A1324

New Jersey Medicare

B1005

New Mexico Blue Cross Blue Shield

A1326

New Mexico Medicaid

A1327

New Mexico Medicare

B1005

New York Blue Cross Blue Shield (Empire)

A1329

New York Medicaid

A1330

New York Medicare

B1005

Nippon Life Insurance (Principal Financial Group)

A1332

North Carolina Blue Cross Blue Shield

A1333

North Carolina Medicaid

A1334

North Carolina Medicare

B1005

North Dakota Blue Cross Blue Shield

A1336

North Dakota Medicaid

A1337

North Dakota Medicare

B1005

Northern Mariana Islands Northern Mariana Medicare

B1005

Ochsner Health Plan

A1340

Ohana Health Plan

A1341

Ohio Anthem Blue Cross Blue Shield

A1342

Ohio Anthem Blue Cross Blue Shield Dental

A1343

Ohio Medicaid

A1344

Ohio Medicare

B1005

Ohio Valley HMO, Cincinnati (Aetna)

A1346

Oklahoma Blue Cross Blue Shield

A1347

Oklahoma Employees Group Insurance

A1348

Oklahoma Medicaid

A1349

Oklahoma Medicare

B1005

OmniCare Health Plan

A1351

Optima

A1506

OptumHealth Behavioral Solutions

A1352

Optum Medical Network (previously Lifeprint)

A1353

Oregon Blue Cross Blue Shield (Regence)

A1354

Oregon Medicaid

A1355

Oregon Medicare

B1005

Oscar Health

A1357

Oxford Health Plans

A1358

Pacific Source Health Plan

A1359

Pacificare Arizona

A1360

Pacificare Oklahoma

A1361

Pacificare Washington

A1362

Palau Medicare

B1005

Pan American Life Puerto Rico

A1364

Paramount

A1365

Parkland Community Health Plan

A1366

Passport Health Plan

A1367

PEHP Utah

A1368

Pennsylvania Blue Cross Blue Shield (Highmark)

A1369

Pennsylvania Medicaid

A1370

Pennsylvania Medicare

B1005

PHCS Savility Payers

A1372

PHP of California

A1373

PHP of Georgia, Atlanta, Aetna

A1374

PHP of Michigan

A1375

PHP of North Ohio, Cleveland, Aetna

A1376

Physicians Mutual Insurance Company

A1377

Preferred Care Partners - Florida

A1378

Preferred Health Systems

A1379

Premera BC Alaska and Washington

A1380

Premier Health

A1381

Prestige Health Choice

A1382

Primary Choice (Aetna Health Plan of NY/NJ)

A1383

Principal Life (Principal Financial Group)

A1503

Priority Health

A1384

Providence Health Plan

A1385

Puerto Rico Medicare

B1005

Qualcare

A1387

QualChoice

A1388

Railroad Medicare

B1005

Rhode Island Blue Cross Blue Shield

A1390

Rhode Island Medicare

B1005

Rocky Mountain Health Plan

A1392

Sanford Health Plan

A1393

Schaller Anderson Aetna Better Health New York

A1394

Schaller Anderson Aetna Better Health Ohio

A1395

Schaller Anderson Aetna Medicaid Illinois

A1396

Schaller Anderson Aetna Medicaid Texas and CHIP

A1397

Schaller Anderson Integral Quality Care Florida

A1398

Schaller Anderson Majestacare Virginia

A1399

Schaller Anderson Maryland Physicians Care

A1400

Schaller Anderson Mercy Care

A1401

Schaller Anderson Missouri Care

A1402

Schaller Anderson Parkland Community

A1403

Schaller Anderson Texas Christus

A1404

Scott and White Health Care Plan

A1405

Select Choice (Aetna Health Plan of NY/NJ)

A1406

SelectHealth

A1407

Select Health South Carolina

A1408

Senior Choice (Aetna Health Plan of NY/NJ)

A1409

Sierra Health Services

A1410

Simply Healthcare

A1411

Soundpath Health

A1412

South Carolina Blue Cross Blue Shield

A1413

South Carolina Medicaid

A1414

South Carolina Medicare

B1005

South Dakota Blue Cross Blue Shield

A1416

South Dakota Medicaid

A1417

South Dakota Medicare

B1005

Southwest Health Plan (Aetna HMO)

A1419

Star HRG

A1420

StayWell

A1421

StayWell Kids

A1422

Surest Health Plan

A1504

Summacare Health Plan

A1423

Tennessee Blue Cross Blue Shield

A1424

Tennessee Medicaid (TennCare)

A1425

Tennessee Medicare

B1005

Texas Blue Cross Blue Shield

A1427

Texas Childrens Health Plan

A1428

Texas Medicaid

A1429

Texas Medicare

B1005

Tribute Health Plan

A1431

Tricare Champus

A1432

Tricare East

A1433

Tricare for Life

A1434

Tricare Overseas

A1435

Tricare West

A1436

Trustmark

A1437

Tufts Health Plan

A1438

UCare Minnesota

A1439

UHCWest (Pacificare)

A1440

U.S. Minor Outlying Islands Medicare

B1005

UMR Wausau

A1442

UMR USNAS

A1443

UMWA Health and Retirement Funds

A1444

UniCare

A1445

UniCare Dental

A1446

Union Pacific Railroad Employees Health Systems

A1447

UnitedHealthcare

A1448

UnitedHealthcare

A1449

UnitedHealthcare Community Plan - Kansas

A1450

UnitedHealthcare Community Plan (OH)

A1451

UnitedHealthcare Community Plan (PA,SC)

A1452

UnitedHealthcare Community Plan - Tennessee

A1453

UnitedHealthcare Dental

A1454

UnitedHealthcare Facets Detroit - Community and State

A1455

UnitedHealthcare Life Insurance Company

A1456

UnitedHealthcare Nevada Market

A1457

UnitedHealthcare River Valley

A1458

UnitedHealthcare Student Resources

A1459

UnitedHealthcare Vision

A1460

Unity Health Insurance

A1461

University Family Care Arizona

A1462

University of Utah Health Plans

A1463

University Physicians Care Advantage Arizona

A1507

UPMC Health Plan (Tristate)

A1464

USAA Life Insurance Company

A1465

USAA Medicare Supplemental

A1466

Utah Blue Cross Blue Shield (Regance)

A1467

Utah Medicaid

A1468

Utah Medicare

B1005

Valley Health Plan

A1470

Vantage Health Plan

A1471

Vermont Medicaid

A1472

Vermont Medicare

B1005

Veterans Affairs Fee Basis Program

A1474

Virgin Islands of the U.S Medicare

B1005

Virginia Anthem Blue Cross Blue Shield

A1476

Virginia Anthem Blue Cross Blue Shield Dental

A1477

Virginia Medicaid

A1478

Virginia Medicare

B1005

Washington Blue Shield (Regence)

A1480

Washington Medicaid

A1481

Washington Medicare

B1005

Washington National

A1483

WEA Trust

A1484

WebTPA Incorporated

A1485

WellCare Health Plans

A1486

Western Health Advantage

A1487

Western New York Blue Cross Blue Shield

A1488

West Virginia Blue Cross Blue Shield

A1489

West Virginia Medicaid

A1490

West Virginia Medicare

B1005

Windsor Health Plan

A1492

Wisconsin Anthem Blue Cross Blue Shield

A1493

Wisconsin Anthem Blue Cross Blue Shield Dental

A1494

Wisconsin Chronic Disease Program

A1495

Wisconsin Medicaid

A1496

Wisconsin Medicare

B1005

Wisconsin Physicians Service Insurance Corporation (WPS)

A1498

Wisconsin Well Woman Program

A1499

Wyoming Blue Cross Blue Shield

A1500

Wyoming Medicaid

A1501

Wyoming Medicare

B1005

EDI Service Type Codes

Name

Value

Medical Care

1 Surgical

2 Consultation

3 Diagnostic X-Ray

4 Diagnostic Lab

5 Radiation Therapy

6 Anesthesia

7 Surgical Assistance

8 Other Medical

9 Blood Charges

10 Used Durable Medical Equipment

11 Durable Medical Equipment Purchase

12 Ambulatory Service Center Facility

13 Renal Supplies in the Home

14 Alternate Method Dialysis

15 Chronic Renal Disease (CRD) Equipment

16 Pre-Admission Testing

17 Durable Medical Equipment Rental

18 Pneumonia Vaccine

19 Second Surgical Opinion

20 Third Surgical Opinion

21 Social Work

22 Diagnostic Dental

23 Periodontics

24 Restorative

25 Endodontics

26 Maxillofacial Prosthetics

27 Adjunctive Dental Services

28 Health Benefit Plan Coverage

30 Plan Waiting Period

32 Chiropractic

33 Chiropractic Office Visits

34 Dental Care

35 Dental Crowns

36 Dental Accidents

37 Orthodontics

38 Prosthodontics

39 Oral Surgery

40 Routine (Preventive) Dental

41 Home Health Care

42 Home Health Prescriptions

43 Home Health Visits

44 Hospice

45 Respite Care

46 Hospital

47 Hospital – Inpatient

48 Hospital – Room and Board

49 Hospital – Outpatient

50 Hospital – Emergency Accident

51 Hospital – Emergency Medical

52 Hospital – Ambulatory Surgical

53 Long Term Care

54 Major Medical

55 Medically Related Transportation

56 Air Transportation

57 Cabulance

58 Licensed Ambulance

59 General Benefits

60 In-vitro Fertilization

61 MRI/CAT Scan

62 Donor Procedures

63 Acupuncture

64 Newborn Care

65 Pathology

66 Smoking Cessation

67 Well Baby Care

68 Maternity

69 Transplants

70 Audiology Exam

71 Inhalation Therapy

72 Diagnostic Medical

73 Private Duty Nursing

74 Prosthetic Device

75 Dialysis

76 Otological Exam

77 Chemotherapy

78 Allergy Testing

79 Immunizations

80 Routine Physical

81 Family Planning

82 Infertility

83 Abortion

84 AIDS

85 Emergency Services

86 Cancer

87 Pharmacy

88 Free Standing Prescription Drug

89 Mail Order Prescription Drug

90 Brand Name Prescription Drug

91 Generic Prescription Drug

92 Podiatry

93 Podiatry – Office Visits

94 Podiatry – Nursing Home Visits

95 Professional (Physician)

96 Anesthesiologist

97 Professional (Physician) Visit – Office

98 Professional (Physician) Visit – Inpatient

99 Professional (Physician) Visit – Outpatient

A0

Professional (Physician) Visit – Nursing Home

A1

Professional (Physician) Visit – Skilled Nursing Facility

A2

Professional (Physician) Visit – Home

A3

Psychiatric

A4

Psychiatric – Room and Board

A5

Psychotherapy

A6

Psychiatric – Inpatient

A7

Psychiatric – Outpatient

A8

Rehabilitation

A9

Rehabilitation – Room and Board

AA

Rehabilitation – Inpatient

AB

Rehabilitation – Outpatient

AC

Occupational Therapy

Physical Medicine

AE

Speech Therapy

AF

Skilled Nursing Care

AG

Skilled Nursing Care – Room and Board

AH

Substance Abuse

AI

Alcoholism

AJ

Drug Addiction

AK

Vision (Optometry)

AL

Frames

AM

Routine Exam

AN

Lenses

AO

Nonmedically Necessary Physical

AQ

Experimental Drug Therapy

AR

Burn Care

B1

Brand Name Prescription Drug – Formulary

B2

Brand Name Prescription Drug – Non-Formulary

B3

Independent Medical Evaluation

BA

Partial Hospitalization (Psychiatric)

BB

Day Care (Psychiatric)

BC

Cognitive Therapy

BD

Massage Therapy

BE

Pulmonary Rehabilitation

BF

Cardiac Rehabilitation

BG

Pediatric

BH

Nursery

BI

Skin

BJ

Orthopedic

BK

Cardiac

BL

Lymphatic

BM

Gastrointestinal

BN

Endocrine

BP

Neurology

BQ

Eye

BR

Invasive Procedures

BS

Gynecological

BT

Obstetrical

BU

Obstetrical/Gynecological

BV

Mail Order Prescription Drug: Brand Name

BW

Mail Order Prescription Drug: Generic

BX

Physician Visit – Office: Sick

BY

Physician Visit – Office: Well

BZ

Coronary Care

C1

Private Duty Nursing – Inpatient

CA

Private Duty Nursing – Home

CB

Surgical Benefits – Professional (Physician)

CC

Surgical Benefits – Facility

CD

Mental Health Provider – Inpatient

CE

Mental Health Provider – Outpatient

CF

Mental Health Facility – Inpatient

CG

Mental Health Facility – Outpatient

CH

Substance Abuse Facility – Inpatient

CI

Substance Abuse Facility - Outpatient

CJ

Screening X-ray

CK

Screening Laboratory

CL

Mammogram, High Risk Patient

CM

Mammogram, Low Risk Patient

CN

Flu Vaccination

CO

Eyewear and Eyewear Accessories

CP

Case Management

CQ

Dermatology

DG

Durable Medical Equipment

DM

Diabetic Supplies

DS

Generic Prescription Drug – Formulary

GF

Generic Prescription Drug – Non-Formulary

GN

Allergy

GY

Intensive Care

IC

Mental Health

MH

Neonatal Intensive Care

NI

Oncology

ON

Physical Therapy

PT

Pulmonary

PU

Renal

RN

Residential Psychiatric Treatment

RT

Transitional Care

TC

Transitional Nursery Care

TN

Urgent Care

UC