Medicare primary and commercial secondary context
Scenario
Section titled “Scenario”This example follows a subscriber with Medicare-primary and commercial-secondary
coverage labels. Two EB statements and a message show how related details can
appear in one subscriber context.
Scenario labels do not establish payer order. Use the actual response, payer or
plan records, and applicable route rules when determining coverage order.
Complete response
Section titled “Complete response”ISA*00* *00* *ZZ*SUMMITBENEFITS *ZZ*LAKESIDEIM *990103*1203*^*00501*000000303*0*P*:~
GS*HB*SUMMITBENEFITS*LAKESIDEIM*20990101*1203*303*X*005010X279A1~
ST*271*0303*005010X279A1~
BHT*0022*11*ELIG3030001*20990101*1203~
HL*1**20*1~
NM1*PR*2*SUMMIT BENEFIT ADMINISTRATORS~
HL*2*1*21*1~
NM1*1P*2*LAKESIDE INTERNAL MEDICINE~
HL*3*2*22*0~
NM1*IL*1*PATEL*AVERY~
EB*1**30**MEDICARE PRIMARY~
EB*1**30**COMMERCIAL SECONDARY~
MSG*REVIEW COORDINATION OF BENEFITS~
SE*12*0303~
GE*1*303~
IEA*1*000000303~Segment breakdown
The entries below follow the source order. Empty fields are shown as(empty); fields not present in a source segment are not added. Stedi links identify public field references; the licensed X279A1 implementation guide supplies the complete transaction rules.
Interchange 1
ISA
Raw segment:
ISA*00* *00* *ZZ*SUMMITBENEFITS *ZZ*LAKESIDEIM *990103*1203*^*00501*000000303*0*P*:~Opens an interchange and establishes its fixed control and delimiter positions. Its control number is 000000303.
ISA fields Position Raw value Field name Explanation ISA0100Authorization Information Qualifier Identifies the format of the authorization information. The value 00 means no authorization information is present. ISA02(blank: 10 spaces)Authorization Information Carries the authorization value; this example leaves the fixed-width value blank. ISA0300Security Information Qualifier Identifies the format of the security information. The value 00 means no security information is present. ISA04(blank: 10 spaces)Security Information Carries the security value; this example leaves the fixed-width value blank. ISA05ZZInterchange ID Qualifier Identifies the type of sender identifier. The value ZZ identifies a mutually defined sender identifier. ISA06SUMMITBENEFITSInterchange Sender ID Identifies the sender of this interchange. ISA07ZZInterchange ID Qualifier Identifies the type of receiver identifier. The value ZZ identifies a mutually defined receiver identifier. ISA08LAKESIDEIMInterchange Receiver ID Identifies the receiver of this interchange. ISA09990103Interchange Date Records the interchange date in YYMMDD format. ISA101203Interchange Time Records the interchange time in HHMM format. ISA11^Repetition Separator Separates repeated composite values in this interchange. ISA1200501Interchange Control Version Number Identifies the interchange control version, 00501 here. ISA13000000303Interchange Control Number Identifies this interchange and must match IEA02. ISA140Acknowledgment Requested Indicates whether an interchange acknowledgment is requested. The value 0 means no interchange acknowledgment is requested. ISA15PInterchange Usage Indicator Indicates whether the interchange is for test, production, or information data. The value P is the code for production data. ISA16:Component Element Separator Separates component values within a composite element. Field reference: Stedi ISA segment reference.
GS
Raw segment:
GS*HB*SUMMITBENEFITS*LAKESIDEIM*20990101*1203*303*X*005010X279A1~Opens a functional group inside the interchange. Its group control number is 303.
GS fields Position Raw value Field name Explanation GS01HBFunctional Identifier Code Identifies a group of application-related transaction sets. The value HB means Eligibility, Coverage or Benefit Information. GS02SUMMITBENEFITSApplication Sender's Code Identifies the party sending the transmission. GS03LAKESIDEIMApplication Receiver's Code Identifies the party receiving the transmission. GS0420990101Date Records the functional group date. GS051203Time Records the functional group time. GS06303Group Control Number Identifies this group and must match GE02. GS07XResponsible Agency Code Identifies the agency responsible for the implementation convention. The value X identifies the responsible agency as X12. GS08005010X279A1Version / Release / Industry Identifier Code Identifies the implementation convention used by the group. Field reference: Stedi GS segment reference.
ST
Raw segment:
ST*271*0303*005010X279A1~Opens a transaction set inside the functional group. This transaction is 271 with control number 0303.
ST fields Position Raw value Field name Explanation ST01271Transaction Set Identifier Code Identifies this response as transaction set 271. The value 271 identifies an eligibility, coverage, or benefit response. ST020303Transaction Set Control Number Identifies this transaction and must match SE02. ST03005010X279A1Implementation Convention Reference Identifies the implementation convention used by the transaction. Field reference: Stedi ST segment reference.
BHT
Raw segment:
BHT*0022*11*ELIG3030001*20990101*1203~Supplies beginning-of-hierarchical-transaction context.
BHT fields Position Raw value Field name Explanation BHT010022Hierarchical Structure Code Identifies the hierarchical structure used by the transaction. The value 0022 means Information Source, Information Receiver, Subscriber, Dependent. BHT0211Transaction Set Purpose Code States the purpose of this transaction set. The value 11 means Response. BHT03ELIG3030001Reference Identification Provides the transaction reference used in this response. BHT0420990101Date Records the date the transaction was created in the business application. BHT051203Time Records the time the transaction was created in the business application. Field reference: Stedi BHT segment reference.
HL
Raw segment:
HL*1**20*1~Establishes one hierarchical level and its optional parent relationship. This level is 1 at the top of the hierarchy.
HL fields Position Raw value Field name Explanation HL011Hierarchical ID Number Identifies this hierarchy level. HL02(empty)Hierarchical Parent ID Number Identifies the parent level; an empty value marks the top level. HL0320Hierarchical Level Code Identifies the kind of entity represented by this level. The value 20 identifies an information-source hierarchy level. HL041Hierarchical Child Code Indicates whether this level has subordinate levels. The value 1 indicates that this level has child levels. Field reference: Stedi HL segment reference.
NM1
Raw segment:
NM1*PR*2*SUMMIT BENEFIT ADMINISTRATORS~Identifies the party attached to the current hierarchy level.
NM1 fields Position Raw value Field name Explanation NM101PREntity Identifier Code Identifies the party role represented by this name loop. The value PR identifies the payer party. NM1022Entity Type Qualifier Identifies whether the party is an individual or organization. The value 2 identifies an organization. NM103SUMMIT BENEFIT ADMINISTRATORSName Last or Organization Name Supplies the party name used in this response. Field reference: Stedi NM1 segment reference.
HL
Raw segment:
HL*2*1*21*1~Establishes one hierarchical level and its optional parent relationship. This level is 2 under parent 1.
HL fields Position Raw value Field name Explanation HL012Hierarchical ID Number Identifies this hierarchy level. HL021Hierarchical Parent ID Number Identifies the parent level; an empty value marks the top level. HL0321Hierarchical Level Code Identifies the kind of entity represented by this level. The value 21 identifies an information-receiver hierarchy level. HL041Hierarchical Child Code Indicates whether this level has subordinate levels. The value 1 indicates that this level has child levels. Field reference: Stedi HL segment reference.
NM1
Raw segment:
NM1*1P*2*LAKESIDE INTERNAL MEDICINE~Identifies the party attached to the current hierarchy level.
NM1 fields Position Raw value Field name Explanation NM1011PEntity Identifier Code Identifies the party role represented by this name loop. The value 1P identifies the provider party. NM1022Entity Type Qualifier Identifies whether the party is an individual or organization. The value 2 identifies an organization. NM103LAKESIDE INTERNAL MEDICINEName Last or Organization Name Supplies the party name used in this response. Field reference: Stedi NM1 segment reference.
HL
Raw segment:
HL*3*2*22*0~Establishes one hierarchical level and its optional parent relationship. This level is 3 under parent 2.
HL fields Position Raw value Field name Explanation HL013Hierarchical ID Number Identifies this hierarchy level. HL022Hierarchical Parent ID Number Identifies the parent level; an empty value marks the top level. HL0322Hierarchical Level Code Identifies the kind of entity represented by this level. The value 22 identifies a subscriber hierarchy level. HL040Hierarchical Child Code Indicates whether this level has subordinate levels. The value 0 indicates that this level has no child levels. Field reference: Stedi HL segment reference.
NM1
Raw segment:
NM1*IL*1*PATEL*AVERY~Identifies the party attached to the current hierarchy level.
NM1 fields Position Raw value Field name Explanation NM101ILEntity Identifier Code Identifies the party role represented by this name loop. The value IL identifies the insured or subscriber party. NM1021Entity Type Qualifier Identifies whether the party is an individual or organization. The value 1 identifies an individual person. NM103PATELName Last or Organization Name Supplies the party name used in this response. NM104AVERYName First Supplies the person’s first name when present. Field reference: Stedi NM1 segment reference.
EB
Raw segment:
EB*1**30**MEDICARE PRIMARY~Reports one qualified eligibility or benefit statement in the current subscriber context. Its status is 1 and its service type is 30.
EB fields Position Raw value Field name Explanation EB011Eligibility or Benefit Information Code States the eligibility or benefit status represented by this statement. The value 1 means Active Coverage. EB02(empty)Coverage Level Code Identifies the coverage level when supplied. EB0330Service Type Code Identifies the service type covered by this statement. The value 30 identifies health benefit plan coverage as the service type. EB04(empty)Insurance Type Code Identifies the insurance type when supplied. EB05MEDICARE PRIMARYPlan Coverage Description Provides the plan or coverage description used in this response. Field reference: Stedi EB segment reference.
EB
Raw segment:
EB*1**30**COMMERCIAL SECONDARY~Reports one qualified eligibility or benefit statement in the current subscriber context. Its status is 1 and its service type is 30.
EB fields Position Raw value Field name Explanation EB011Eligibility or Benefit Information Code States the eligibility or benefit status represented by this statement. The value 1 means Active Coverage. EB02(empty)Coverage Level Code Identifies the coverage level when supplied. EB0330Service Type Code Identifies the service type covered by this statement. The value 30 identifies health benefit plan coverage as the service type. EB04(empty)Insurance Type Code Identifies the insurance type when supplied. EB05COMMERCIAL SECONDARYPlan Coverage Description Provides the plan or coverage description used in this response. Field reference: Stedi EB segment reference.
MSG
Raw segment:
MSG*REVIEW COORDINATION OF BENEFITS~Carries explanatory text associated with the surrounding response context.
MSG fields Position Raw value Field name Explanation MSG01REVIEW COORDINATION OF BENEFITSFree-Form Message Text Provides the explanatory text carried by this response. Field reference: Stedi MSG segment reference.
SE
Raw segment:
SE*12*0303~Closes a transaction set and declares its segment count. It closes transaction 0303.
SE fields Position Raw value Field name Explanation SE0112Number of Included Segments Counts segments from ST through SE. SE020303Transaction Set Control Number Matches ST02 for this transaction. Field reference: Stedi SE segment reference.
GE
Raw segment:
GE*1*303~Closes a functional group and declares its transaction count. It closes group 303.
GE fields Position Raw value Field name Explanation GE011Number of Transaction Sets Included Counts transaction sets in this functional group. GE02303Group Control Number Matches GS06 for this functional group. Field reference: Stedi GE segment reference.
IEA
Raw segment:
IEA*1*000000303~Closes an interchange and declares its group count. It closes the interchange with control number 000000303.
IEA fields Position Raw value Field name Explanation IEA011Number of Included Functional Groups Counts functional groups in this interchange. IEA02000000303Interchange Control Number Matches ISA13 for this interchange. Field reference: Stedi IEA segment reference.