Eligibility and benefit statements

An EB segment reports eligibility or benefit information for a specific context. Its meaning depends on the person and hierarchy around it, the requested service, coverage level, time period, and the values returned by the payer.

EB example

Public EB element references show fields used for benefit status, service type, coverage level, insurance type, time period, amounts, percentages, and quantities. A response can repeat benefit statements for different services or conditions. Authorization and network indications can further qualify a statement when the transaction profile and payer return those values.

The single-benefit example uses a short statement:

EB*1**30**SILVER PPO~

• EB01=1 reports active coverage.
• EB02 is empty, so this statement does not supply a coverage-level value.
• EB03=30 identifies health benefit plan coverage as the service type.
• EB04 is empty, so this statement does not supply an insurance-type value.
• EB05=SILVER PPO is the plan description used in this example.

That line provides one statement in its surrounding subscriber context. Read the other benefit statements, dates, and payer instructions before deciding the member’s coverage or payer order.

LS and LE example

LS and LE mark the start and end of a named loop. This excerpt adapts the additional-payer pattern in the UnitedHealthcare companion guide:

EB*R**30~
LS*2120~
NM1*PR*2*RIVERBEND HEALTH PLAN~
LE*2120~

LS01=2120 and LE01=2120 carry the same loop identifier. The NM1 between them identifies the related payer in this example. The applicable 271 guide determines when this loop is used; the generic LS and LE references only define the control pair.

DTP example

DTP supplies a date, time, or period associated with the surrounding loop:

DTP*291*D8*20990101~

• DTP01=291 identifies the date as a plan date in this example.
• DTP02=D8 says that DTP03 contains one date in CCYYMMDD form.
• DTP03=20990101 is January 1, 2099.

See the public DTP field reference.

HSD example

UnitedHealthcare publishes this benefit limitation example:

EB*F*IND*96*********Y~
HSD*VS*5***34*6~

In that guide, HSD01=VS means visits, HSD02=5 supplies the quantity, HSD05=34 identifies months, and HSD06=6 supplies the number of periods. Together, the two segments describe a five-visit limit over six months. Those code meanings are stated for the UnitedHealthcare example; do not apply the entire pattern to another payer without checking its guide. See the generic HSD field reference and the UnitedHealthcare companion guide.

REF example

REF carries an identifier whose meaning depends on its qualifier and loop:

REF*6P*RB12345~

REF01=6P is the qualifier, and REF02=RB12345 is the example identifier. The segment alone does not establish what that identifier means. Read it with its loop and the applicable payer or intermediary guide. See the public REF field reference.

MSG example

MSG adds text to its surrounding benefit context:

EB*1**30**MEDICARE ADVANTAGE PLAN~
MSG*MEDICARE ADVANTAGE COVERAGE REPORTED~

MSG01 contains the text. Its meaning comes from the eligibility or benefit loop that contains it. See the public MSG field reference. X12’s RFI 2628 describes another 271 use of MSG.

Interpret the whole context

Read an EB with its HL, NM1, dates, identifiers, limits, and explanatory text. Payer instructions may further restrict the values and qualifiers.