| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | eb number | 0;1 | NUMERIC | B | This is a sequential number corresponding to the Set-ID for all of the eligibility/benefit (X.12 EB segments) segments coming into VISTA. | |
| .02 | eligibility/benefit info | 0;2 | POINTER | 365.011 | This field contains a code identifying the eligibility status of the individual or the benefit returned by the Payer. | |
| .03 | coverage level | 0;3 | POINTER | 365.012 | This field identifies the level of coverage of benefits. | |
| .04 | *service type | 0;4 | POINTER | 365.013 | This field is a code identifying the classification of service. | |
| .05 | insurance type | 0;5 | POINTER | 365.014 | This is a code identifying the type of insurance policy within a specific insurance program. | |
| .06 | plan coverage description | 0;6 | FREE TEXT | This code is a description or number that identifies the plan or coverage. | ||
| .07 | time period qualifier | 0;7 | POINTER | 365.015 | This is a code for the time period category that determines for how long the benefits are available. | |
| .08 | monetary amount | 0;8 | FREE TEXT | This field is populated if eligibility or benefit must be qualified by a monetary amount. | ||
| .09 | percent | 0;9 | NUMERIC | This field is used if eligibility or benefit must be qualified by a percentage. | ||
| .1 | quantity qualifier | 0;10 | POINTER | 365.016 | This field is used to identify the type of units that are being conveyed in the QUANTITY field (#.11). | |
| .11 | quantity | 0;11 | FREE TEXT | This field number is used for the quantity value as qualified by the QUANTITY QUALIFIER field. | ||
| .12 | authorization/certification | 0;12 | POINTER | 365.033 | This field indicates that an authorization or certification is required per plan provisions. | |
| .13 | in plan | 0;13 | POINTER | 365.033 | This field indicates the plan network indicator. A YES value indicates the benefits identified are considered In-Plan-Network. A NO value indicates that the benefits identified are considered Out-Of-Plan-Network. A "U" value indicates it is unknown whether the benefits identified are part of the Plan Network. | |
| 1.01 | procedure coding method | 1;1 | POINTER | 365.035 | Two character code describing procedure coding method. | |
| 1.02 | procedure code | 1;2 | FREE TEXT | Identification code for the procedure. | ||
| 1.03 | procedure modifier 1 | 1;3 | FREE TEXT | Identifies special circumstances related to the procedure; first modifier. | ||
| 1.04 | procedure modifier 2 | 1;4 | FREE TEXT | Identifies special circumstances related to the procedure; second modifier. | ||
| 1.05 | procedure modifier 3 | 1;5 | FREE TEXT | Identifies special circumstances related to the procedure; third modifier. | ||
| 1.06 | procedure modifier 4 | 1;6 | FREE TEXT | Identifies special circumstances related to the procedure; fourth modifier. | ||
| 2 | notes | 2;0 | WORD-PROCESSING | This field contains any additional text about the eligibility benefit information. It is transcribed from X.12 271 MSG segments. | ||
| 3.01 | entity id code | 3;1 | POINTER | 365.022 | X12 Entity Identifier Code. | |
| 3.02 | entity type | 3;2 | POINTER | 365.043 | Describes the type of Entity. | |
| 3.03 | name | 3;3 | FREE TEXT | Name of person or organization. | ||
| 3.04 | entity id | 3;4 | FREE TEXT | Entity identifier. | ||
| 3.05 | entity id qualifier | 3;5 | POINTER | 365.023 | Code designating the system/method used for Identification. | |
| 3.06 | entity relationship code | 3;6 | POINTER | 365.031 | Benefit Related Entity's relationship to the patient. | |
| 4.01 | address line 1 | 4;1 | FREE TEXT | Entity address, line 1. | ||
| 4.02 | address line 2 | 4;2 | FREE TEXT | Entity address, line 2. | ||
| 4.03 | city | 4;3 | FREE TEXT | Entity address, city. | ||
| 4.04 | state | 4;4 | POINTER | 5 | Entity address, state or province code. | |
| 4.05 | zip | 4;5 | FREE TEXT | Entity address, zip or postal code. | ||
| 4.06 | country code | 4;6 | FREE TEXT | Entity address, country code. | ||
| 4.07 | location | 4;7 | FREE TEXT | Entity address, location identifier. | ||
| 4.08 | location qualifier | 4;8 | POINTER | 365.034 | Entity address, location qualifier. | |
| 4.09 | subdivision code | 4;9 | FREE TEXT | Entity address, country subdivision code. | ||
| 5.01 | provider code | 5;1 | POINTER | 365.024 | Code identifying the type of provider. | |
| 5.02 | reference id | 5;2 | FREE TEXT | Reference identifier. | ||
| 5.03 | reference id qualifier | 5;3 | POINTER | 365.028 | Reference identifier type. | |
| 6 | contact information | 6;0 | MULTIPLE | 365.26 | This multiple contains contact information for an eligibility/benefit entity. | |
| 7 | healthcare services delivery | 7;0 | MULTIPLE | 365.27 | Healthcare services delivery multiple. | |
| 8 | subscriber dates | 8;0 | MULTIPLE | 365.28 | Subscriber dates multiple. | |
| 9 | subscriber additional info | 9;0 | MULTIPLE | 365.29 | Additional subscriber information multiple. | |
| 10 | subscriber reference id | 10;0 | MULTIPLE | 365.291 | Subscriber reference id multiple. | |
| 14 | service types | 14;0 | MULTIPLE | 365.292 | Contains the Service type codes returned from eligibility inquiry. |
Error: Invalid Global File Type: 365.02