Eligibility Enumerations

This document contains the definitions of the enumerations used in submitted eligibility requests and in payer responses.

BenefitInformationType

Unknown = 0
ActiveCoverage = 1
ActiveFullRiskCapitation = 2
ActiveServicesCapitated = 3
ActiveServicesCapitatedToPrimaryCarePhysician = 4
ActivePendingInvestigation = 5
Inactive = 6
InactivePendingEligibilityUpdate = 7
InactivePendingInvestigation = 8
CoInsurance = 9
CoPayment = 10
Deductible = 11
BenefitDescription = 12
Exclusions = 13
Limitations = 14
OutOfPocketStopLoss = 15
Unlimited = 16
NonCovered = 17
CostContainment = 18
Reserve = 19
PrimaryCareProvider = 20
PreExistingCondition = 21
ServicesRestrictedToFollowingProvider = 22
NotDeemedAMedicalNecessity = 23
BenefitDisclaimer = 24
SecondSurgicalOpinionRequired = 25
OtherOrAdditionalPayor = 26
PriorYearSHistory = 27
CardSReportedLostStolen = 28
ContactFollowingEntityForEligibilityOrBenefitInformation = 29
CannotProcess = 30
OtherSourceOfData = 31
HealthCareFacility = 32
SpendDown = 33
CoverageBasis = 34
ManagedCareCoordinator = 35

BenefitStatus

Unknown = 0
AllInvalid = 1
ResultsComplete = 2
ResultsIncomplete = 3

CoverageLevel

Unknown = 0
ChildrenOnly = 1
DependentsOnly = 2
EmployeeAndChildren = 3
EmployeeOnly = 4
EmployeeAndSpouse = 5
Family = 6
Individual = 7
SpouseAndChildren = 8
SpouseOnly = 9

DiagnosticCodeType

Unknown = 0
Icd9 = 1
Icd10 = 2
Snodent = 3

EligibilityProcedureCodeSource

Unknown = 0
Ada = 1 (AD) American Dental Association
Cpt = 2 (CJ) Current Procedural Terminology
Hcpcs = 3 (HC) Healthcare Common Procedure Coding System
Icd9 = 4 (ID) International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
Hiec = 5 (IV) Home Infusion EDI Coalition
Ndc = 5 (N4) National Drug Code in 5-4-2 format
MutuallyDefined = 6 (ZZ)

EntityType

Unknown = 0
Individual = 1
Organization< = 2/li>

FollowupAction

Unknown = 0
PleaseCorrectAndResubmit = 1
ResubmissionNotAllowed = 2
ResubmissionAllowed = 3
DoNotResubmitInquiryInitiatedToAThirdParty = 4
PleaseWait30DaysAndResubmit = 5
PleaseWait10DaysAndResubmit = 6
DoNotResubmitWeWillHoldYourRequestAndRespondAgainShortly = 7

Gender

Unknown = 0
Male = 1
Female = 2

InformationStatus

Unknown = 0
Partial = 1
Current = 2
Latest = 3
Oldest = 4
Prior = 5
SecondMostCurrent = 6
ThirdMostCurrent = 7

InsuranceType

Unknown = 0
Disability = 1
MedicarePos = 2
MedicareAdvantagePos = 3
MultipleOptionsHealthPlan = 4
MedicareSecondaryWorkingAgedGroupHealthPlan = 5
MedicareSecondaryEndStageRenalGroupHealthPlan = 6
MedicareSecondaryNofault = 7
MedicareSecondaryWorkersCompensation = 8
MedicareSecondaryPublicHealth = 9
Dental = 10
Vision = 11
PrescriptionDrugs = 12
MedicareSecondaryBlackLung = 13
MedicareSecondaryVeteransAdministration = 14
MedicareSecondaryDisabledUnder65GroupHealthPlan = 15
MedicareSecondaryOtherLiability = 16
AutoInsurancePolicy = 17
Commercial = 18
Cobra = 19
MedicareConditionallyPrimary = 20
DisabilityBenefits = 21
ExclusiveProviderOrganization = 22
FamilyOrFriends = 23
GroupPolicy = 24
Hmo = 25
HmoMedicareRisk = 26
SpecialLowIncomeMedicare = 27
Indemnity = 28
IndividualPolicy = 29
LongTermCare = 30
LongTermPolicy = 31
LifeInsurance = 32
Litigation = 33
MedicarePartA = 34
MedicarePartB = 35
Medicaid = 36
MedicarePartD = 37
MedicareAdvantagePpo = 38
MedicareAdvantageFeeForService = 39
MedigapPartA = 40
MedigapPartB = 41
MedicareAdvantageHmo = 42
MedicareAdvantageHmoRisk = 43
MedicareAdvantageIndemnity = 44
MedicareAdvantagePpoPartD = 45
MedicareAdvantageIndemnityNoPartD = 46
MedicareAdvantagePosPartD = 47
MedicarePrimary = 48
MedicareAdvantageRiskHmoNoPartD = 49
MedicareAdvantageHmoNoPartD = 50
MedicareAdvantage = 51
Other = 52
PropertyInsurancePersonal = 53
Personal = 54
PersonalPayment = 55
Ppo = 56
Pos = 57
QualifiedMedicareBeneficiary = 58
PropertyInsuranceReal = 59
SupplementalPolicy = 60
Tefra = 61
WorkersCompensation = 62
WrapUpPolicy = 63

PayeeType

Unknown = 0
Provider = 1 (1P)
ThirdPartyAdministrator = 2 (2B)
Employer = 3 (36)
Hospital = 4 (80)
Facility = 5 (FA)
GatewayProvider = 6 (GP)
PlanSponsor = 7 (P5)
Payer = 8 (PR)

PayerResponseType

Unknown = 0
ClaimStatus = 1
RemittanceAdvice = 2
EmdeonClaimStatus = 3
InterchangeStatus = 4
BenefitResponse = 5

PayerType

Unknown = 0
ThirdPartyAdministrator = 1 (2B)
Employer = 2 (36)
GatewayProvider = 3 (GP)
PlanSponsor = 4 (P5)
Payer = 5 (PR)

PlaceOfServiceCode

Unknown = 0
Pharmacy = 1
School = 2
HomelessShelter = 3
IhsFreestandingFacility = 4
IhsProviderFacility = 5
Tribal638FreestandingFacility = 6
Tribal638ProviderFacility = 7
CorrectionalFacility = 8
Office = 9
Home = 10
AssistedLivingFacility = 11
GroupHome = 12
MobileUnit = 13
TemporaryLodging = 14
WalkinRetailHealthClinic = 15
PlaceOfEmploymentWorksite = 16
UrgentCareFacility = 17
InpatientHospital = 18
OutpatientHospital = 19
EmergencyRoomHospital = 20
AmbulatorySurgicalCenter = 21
BirthingCenter = 22
MilitaryTreatmentFacility = 23
SkilledNursingFacility = 24
NursingFacility = 25
CustodialCareFacility = 26
Hospice = 27
AmbulanceLand = 28
AmbulanceAirOrWater = 29
IndependentClinic = 30
FederallyQualifiedHealthCenter = 31
InpatientPsychiatricFacility = 32
PsychiatricFacilityPartialHospitalization = 33
CommunityMentalHealthCenter = 34
IntermediateCareMentalFacility = 35
ResidentialSubstanceAbuseTreatmentFacility = 36
PsychiatricResidentialTreatmentCenter = 37
NonresidentialSubstanceAbuseTreatmentFacility = 38
MassImmunizationCenter = 39
ComprehensiveInpatientRehabilitationFacility = 40
ComprehensiveOutpatientRehabilitationFacility = 41
EndstageRenalDiseaseTreatmentFacility = 42
PublicHealthClinic = 43
RuralHealthClinic = 44
IndependentLaboratory = 45
OtherPlaceOfService = 46

ProviderRole

Unknown = 0
Hospital = 1 (H)
RuralHealthClinic = 2 (R)
Admitting = 3 (AD)
Attending = 5 (AT)
Billing = 6 (BI)
Consulting = 7 (CO)
Covering = 8 (CV)
HomeHealthCare = 9 (HH)
Laboratory = 10 (LA)
OtherPhysician = 14 (OT)
Pharmacist = 15 (P1)
Pharmacy = 16 (P2)
PrimaryCarePhysician = 17 (PC)
Performing = 18 (PE)
Referring = 21 (RF)
Submitting = 22 (SB)
SkilledNursingFacility = 23 (SK)
Supervising = 24 (SU)

QuantityUnits

Unknown = 0
Minimum = 1
AcknowledgedQuantity = 2
QuantityUsed = 3
UnacknowledgedQuantity = 4
CoveredActual = 5
CoinsuredActual = 6
CoveredEstimated = 7
NumberOfCoInsuranceDays = 8
DeductibleBloodUnits = 9
Days = 10
Units = 11
Hours = 12
LifetimeReserveActual = 13
LifetimeReserveEstimated = 14
Maximum = 15
Month = 16
NonCoveredEstimated = 17
NotReplacedBloodUnits = 18
OutlierDays = 19
NumberOfServicesOrProcedures = 20
Prescription = 21
Patients = 22
QuantityApproved = 23
QuantityDisapproved = 24
AgeHighValue = 25
AgeLowValue = 26
Visits = 27
Years = 28
FederalMedicareOrMedicaidPaymentMandateCategory1 = 29
FederalMedicareOrMedicaidPaymentMandateCategory2 = 30
FederalMedicareOrMedicaidPaymentMandateCategory3 = 31
FederalMedicareOrMedicaidPaymentMandateCategory4 = 32
FederalMedicareOrMedicaidPaymentMandateCategory5 = 33

RejectReason

Unknown = 0
RequiredDataMissing = 1
NotAuthorized = 2
InvalidProviderIdentification = 3
InvalidProviderName = 4
InvalidProviderSpecialty = 5
InvalidProviderPhoneNumber = 6
InvalidProviderState = 7
InvalidReferringProviderIdNumber = 8
ProviderIneligibleForInquiries = 9
ProviderNotOnFile = 10
InvalidParticipantId = 11
InvalidProviderAddress = 12
PayerNameOrIdentifierMissing = 13
InvalidPayerIdentification = 14
InvalidSubscriberIdentification = 15
InvalidSubscriberBirthDate = 16
InvalidSubscriberName = 17

Relationship

Invalid = 0
Spouse = 1
Self = 2
Child = 3
Employee = 4
RelationshipUnknown = 5
OtherAdult = 6
OrganDonor = 7
CadaverDonor = 8
LifePartner = 9
OtherRelationship = 10

RequestType

Unknown = 0
Request = 1
SpendDownRequest = 2
SpendDownCancellation = 3

ResponseServiceStatus

Unknown = 0
ActiveReserve = 1
ActiveMilitaryOverseas = 2
AcademyStudent = 3
PresidentialAppointee = 4
ActiveMilitaryUsa = 5
Contractor = 6
DishonorablyDischarged = 7
HonorablyDischarged = 8
InactiveReserves = 9
MilitaryLeaveOfAbsence = 10
PlanToEnlist = 11
Recommissioned = 12
RetiredMilitaryOverseas = 13
RetiredWithoutRecall = 14
RetiredMilitaryUs = 15

ServiceAffiliation

Unknown = 0
AirForce = 1
AirForceReserves = 2
Army = 3
ArmyReserves = 4
CoastGuard = 5
MarineCorps = 6
MarineCorpsReserves = 7
NationalGuard = 8
Navy = 9
NavyReserves = 10
Other = 11
PeaceCorp = 12
RegularArmedForces = 13
Reserves = 14
USPublicHealthService = 15
ForeignMilitary = 16
AmericanRedCross = 17
DepartmentOfDefense = 18
UnitedServicesOrganization = 19
MilitarySealiftCommand = 20

ServiceRank

Unknown = 0
Admiral = 1
Airman = 2
AirmanFirstClass = 3
BasicAirman = 4
BrigadierGeneral = 5
Captain = 6
ChiefMasterSergeant = 7
ChiefPettyOfficer = 8
ChiefWarrant = 9
Colonel = 10
Commander = 11
Commodore = 12
Corporal = 13
CorporalSpec4 = 14
Ensign = 15
FirstLieutenant = 16
FirstSergeant = 17
FirstSergeantMasterSergeant = 18
FleetAdmiral = 19
General = 20
GunnerySergeant = 21
LanceCorporal = 22
Lieutenant = 23
LieutenantColonel = 24
LieutenantCommander = 25
LieutenantGeneral = 26
LieutenantJuniorGrade = 27
Major = 28
MajorGeneral = 29
MasterChiefPettyOfficer = 30
MasterGunnerySergeantMajor = 31
MasterSergeant = 32
MasterSergeantSpec8 = 33
PettyOfficerFirstClass = 34
PettyOfficerSecondClass = 35
PettyOfficerThirdClass = 36
Private = 37
PrivateFirstClass = 38
RearAdmiral = 39
Recruit = 41
Seaman = 42
SeamanApprentice = 43
SeamanRecruit = 44
SecondLieutenant = 45
SeniorChiefPettyOfficer = 46
SeniorMasterSergeant = 47
Sergeant = 48
SergeantFirstClassSpec7 = 49
SergeantMajorSpec9 = 50
SergeantSpec5 = 51
StaffSergeant = 52
StaffSergeantSpec6 = 53
TechnicalSergeant = 54
ViceAdmiral = 55
WarrantOfficer = 56

ServiceTypeCode

https://x12.org/codes/service-type-codes

Unknown = 0
MedicalCare = 1 (1)
Surgical = 2 (2)
Consultation = 3 (3)
DiagnosticXRay = 4 (4)
DiagnosticLab = 5 (5)
RadiationTherapy = 6 (6)
Anesthesia = 7 (7)
SurgicalAssistance = 8 (8)
BloodCharges = 12 (10)
UsedDurableMedicalEquipment = 13 (11)
DurableMedicalEquipmentPurchase = 14 (12)
AmbulatoryServiceCenterFacility = 15 (13)
RenalSuppliesInTheHome = 16 (14)
AlternateMethodDialysis = 17 (15)
ChronicRenalDiseaseCrdEquipment = 18 (16)
PreAdmissionTesting = 19 (17)
DurableMedicalEquipmentRental = 20 (18)
PneumoniaVaccine = 21 (19)
SecondSurgicalOpinion = 22 (20)
ThirdSurgicalOpinion = 23 (21)
SocialWork = 24 (22)
DiagnosticDental = 25 (23)
Periodontics = 26 (24)
Restorative = 27 (25)
Endodontics = 28 (26)
MaxillofacialProsthetics = 29 (27)
AdjunctiveDentalServices = 30 (28)
HealthBenefitPlanCoverage = 31 (30) - the most general value
Plan Waiting Period = 33 (32)
Chiropractic = 34 (33)
ChiropracticOfficeVisits = 35 (34)
DentalCare = 36 (35)
DentalCrowns = 37 (36)
DentalAccident = 38 (37)
Orthodontics = 39 (38)
Prosthodontics = 40 (39)
OralSurgery = 41 (40)
RoutinePreventiveDental = 42 (41)
HomeHealthCare = 43 (42)
HomeHealthPrescriptions = 44 (43)
HomeHealthVisits = 45 (44)
Hospice = 46 (45)
RespiteCare = 47 (46)
Hospital = 48 (47)
HospitalInpatient = 49 (48)
HospitalRoomAndBoard = 50 (49)
HospitalOutpatient = 51 (50)
HospitalEmergencyAccident = 52 (51)
HospitalEmergencyMedical = 53 (52)
HospitalAmbulatorySurgical = 54 (53)
LongTermCare = 55 (54)
MajorMedical = 56 (55)
MedicallyRelatedTransportation = 57 (56)
AirTransportation = 58 (57)
Cabulance = 59 (58)
Licensed Ambulance = 60 (59)
GeneralBenefits = 61 (60)
InVitroFertilization = 62 (61)
MriCatScan = 63 (62)
DonorProcedures = 64 (63)
Acupuncture = 65 (64)
NewbornCare = 66 (65)
Pathology = 67 (66)
SmokingCessation = 68 (67)
WellBabyCare = 69 (68)
Maternity = 70 (69)
Transplants = 71 (70)
AudiologyExam = 72 (71)
InhalationTherapy = 73 (72)
DiagnosticMedical = 74 (73)
PrivateDutyNursing = 75 (74)
ProstheticDevice = 76 (75)
Dialysis = 77 (76)
OtologicalExam = 78 (77)
Chemotherapy = 79 (78)
AllergyTesting = 80 (79)
Immunizations = 81 (80)
RoutinePhysical = 82 (81)
FamilyPlanning = 83 (82)
Infertility - 84 (83)
Abortion = 85 (84)
AIDS = 86 (85)
EmergencyServices = 87 (86)
Cancer = 88 (87)
Pharmacy = 89 (88)
FreeStandingPrescriptionDrug = 90 (89)
MailOrder PrescriptionDrug = 91 (90)
BrandName PrescriptionDrug = 92 (91)
Generic Prescription Drug = 93 (92)
Podiatry = 94 (93)
PodiatryOfficeVisits = 95 (94)
PodiatryNursingHomeVisits = 96 (95)
ProfessionalPhysician = 97 (96)
Anesthesiologist = 98 (97)
ProfessionalPhysicianVisitOffice = 99 (98)
ProfessionalPhysicianVisitInpatient = 100 (99)
ProfessionalPhysicianVisitOutpatient = 101 (A0)
ProfessionalPhysicianVisitNursingHome = 102 (A1)
ProfessionalPhysicianVisitSkilledNursingFacility = 103 (A2)
ProfessionalPhysicianVisitHome = 104 (A3)
Psychiatric = 105 (A4)
PsychiatricRoomAndBoard = 106 (A5)
Psychotherapy = 107 (A6)
PsychiatricInpatient = 108 (A7)
PsychiatricOutpatient = 109 (A8)
Rehabilitation = 110 (A9)
RehabilitationRoomAndBoard = 111(AA)
RehabilitationInpatient = 112 (AB)
RehabilitationOutpatient = 113 (AC)
OccupationalTherapy = 114 (AD)
PhysicalMedicine = 115 (AE)
SpeechTherapy = 116 (AF)
SkilledNursingCare = 117 (AG)
SkilledNursingCareRoomAndBoard = 118 (AH)
SubstanceAbuse = 119 (AI)
Alcoholism = 120 (AJ)
DrugAddiction = 121 (AK)
VisionOptometry = 122 (AL)
Frames = 123 (AM)
RoutineExam = 124 (AN)
Lenses = 125 (AO)
NonmedicallyNecessaryPhysical = 127 (AQ)
ExperimentalDrugTherapy = 128 (AR)
BurnCare = 129 (B1)
BrandNamePrescriptionDrugFormulary = 130 (B2)
BrandNamePrescriptionDrugNonFormulary = 131 (B3)
IndependentMedicalEvaluation = 132 (BA)
PartialHospitalizationPsychiatric = 133 (BB)
DayCarePsychiatric) = 134 (BC)
CognitiveTherapy = 135 (BD)
MassageTherapy = 136 (BE)
PulmonaryRehabilitation = 137 (BF)
CardiacRehabilitation = 138 (BG)
Pediatric = 139 (BH)
Nursery = 140 (BI)
Skin = 141 (BJ)
Orthopedic = 142 (BK)
Cardiac = 143 (BL)
Lymphatic = 144 (BM)
Gastrointestinal = 145 (BN)
Endocrine = 146 (BP)
Neurology = 147 (BQ)
Eye = 148 (BR)
InvasiveProcedures = 149 (BS)
Gynecological = 150 (BT)
Obstetrical = 151 (BU)
ObstetricalGynecological = 152 (BV)
MailOrderPrescriptionDrugBrandName = 153 (BW)
MailOrderPrescriptionDrugGeneric = 154 (BX)
PhysicianVisitOfficeSick = 155 (BY)
PhysicianVisitOfficeWell = 156 (BZ)
CoronaryCare = 157 (C1)
PrivateDutyNursingInpatient = 158 (CA)
PrivateDutyNursingHome = 159 (CB)
SurgicalBenefitsProfessionalPhysician = 160 (CC)
SurgicalBenefitsFacility = 161 (CD)
MentalHealthProviderInpatient = 162 (CE)
MentalHealthProviderOutpatient = 163 (CF)
MentalHealthFacilityInpatient = 164 (CG)
MentalHealthFacilityOutpatient = 165 (CH)
SubstanceAbuseFacilityInpatient = 166 (CI)
SubstanceAbuseFacilityOutpatient = 167 (CJ)
ScreeningXRay = 168 (CK)
Screeninglaboratory = 169 (CL)
MammogramHighRiskPatient = 170 (CM)
MammogramLowRiskPatient = 171 (CN)
FluVaccination = 172 (CO)
EyewearAndEyewearAccessories = 173 (CP)
CaseManagement = 174 (CQ)
Dermatology = 175 (DG)
DurableMedicalEquipment = 176 (DM)
DiabeticSupplies = 177 (DS)
GenericPrescriptionDrugFormulary = 178 GF)
GenericPrescriptionDrugNonFormulary = 179 (GN)
Allergy = 180 (GY)
IntensiveCare = 181 (IC)
MentalHealth = 182 (MH)
NeonatalIntensiveCare = 183 (NI)
Oncology = 184 (ON)
PhysicalTherapy = 186 (PT)
Pulmonary = 187 (PU)
Renal = 188 (RN)
ResidentialPsychiatricTreatment = 189 (RT)
TransitionalCare = 190 (TC)
TransitionalNurseryCare = 191 (TN)
UrgentCare = 192 (UC)

TimePeriod

Unknown = 0
Hour = 1
Day = 2
TwentyFourHours = 3
Years = 4
ServiceYear = 5
CalendarYear = 6
YearToDate = 7
Contract = 8
Episode = 9
Visit = 10
Outlier = 11
Remaining = 12
Exceeded = 13
NotExceeded = 14
Lifetime = 15
LifetimeRemaining = 16
Month = 17
Week = 18
Admission = 19

YesOrNo

Unknown = 0
No = 1
NotApplicable = 2
Yes = 3