Eligibility Codes (EB01) - Registry Setting

Avatar PM > Billing > Electronic Submissions > Eligibility Inquiry & Response (270/271)

Define benefit information used to determine client eligibility.

The Eligibility Verified field in the Financial Eligibility form will update based on this setting.

At least one of the codes entered in this registry setting must be returned in the 271 request file (2110-EB-01 segment).

Separate multiple codes with '&', with no spaces.

1 - Active Coverage

2 - Active - Full Risk Capitation

3 - Active - Services Capitated

4 - Active - Services Capitated to Primary Care Physician

5 - Active - Pending Investigation

6 - Inactive

7 - Inactive - Pending Eligibility Update

8 - Inactive - Pending Investigation

A - Co-Insurance

B - Co-Payment

C - Deductible

CB - Coverage Basis

D - Benefit Description

E - Exclusions

F - Limitations

G - Out of Pocket (Stop Loss)

H - Unlimited

I - Non-Covered

J - Cost Containment

K - Reserve

L - Primary Care Provider

M - Pre-existing Condition

MC - Managed Care Coordinator

N - Services Restricted to Following Provider

O - Not Deemed a Medical Necessity

P - Benefit Disclaimer

Q - Second Surgical Opinion Required

R - Other or Additional Payor

S - Prior Year(s) History

T - Card(s) Reported Lost/Stolen

U - Contact Following Entity for Eligibility or Benefit Information

V - Cannot Process

W - Other Source Data

X - Health Care Facility

Y - Spend Down