SBI Specific Benefit Information

Opt

AtMax 20

To specify specifc benefit scenarios

Elements

Position	Element	Name		Type	Min/Max	Repeat

1	1390	Eligibility or Benefit Information Code	Mandatory	ID	1/2	AtMax 1
2	615	Time Period Qualifier	Rel	ID	1/2	AtMax 1
3	616	Number of Periods	Opt	Number	1/3	AtMax 1
4	954	Percentage as Decimal	Opt	Decimal	1/10	AtMax 1
5	782	Monetary Amount	Opt	Decimal	1/18	AtMax 1
6	782	Monetary Amount	Opt	Decimal	1/18	AtMax 1
7	1790	Tier identifier	Opt	Number	1/2	AtMax 1
8	1204	Plan Coverage Description	Opt	Alphanumeric	1/50	AtMax 1
9	1073	Yes/No Condition or Response Code	Opt	ID	1/1	AtMax 1
10	1073	Yes/No Condition or Response Code	Opt	ID	1/1	AtMax 1
11	782	Monetary Amount	Opt	Decimal	1/18	AtMax 1

Element Details

ID1390

NameEligibility or Benefit Information Code

LengthMin 1 / Max 2

Position1

RequirementMandatory

Codes

<>L
Primary Care Provider
<>G
Out of Pocket (Stop Loss)
<>7
Inactive - Pending Eligibility Update
<>W
Other Source of Data
<>AC
Co-insurance Maximum
<>HR
Health Reimbursement Account
<>J
Cost Containment
<>SF
Simple Forward Rolling Limitation (SFRL)
<>M
Pre-existing Condition
<>CF
Combination Forward Rolling Limitation (CFRL)
<>P
Benefit Disclaimer
<>K
Reserve
<>12
Inactive - Pending Receipt of Premium Payment
<>AB
Co-payment Maximum
<>N
Services Restricted to Following Provider
<>FG
First Dollar Coverage, Group of Services
<>A
Co-Insurance
<>1
Active Coverage
<>Q
Second Surgical Opinion Required
<>D
Benefit Description
<>4
Active - Services Capitated to Primary Care Physician
<>T
Card(s) Reported Lost/Stolen
<>SD
Shared Benefit Deductible
<>O
Not Deemed a Medical Necessity
<>B
Co-Payment
<>2
Active - Full Risk Capitation
<>R
Other or Additional Payor
<>FD
First Dollar Coverage
<>E
Exclusions
<>5
Active - Pending Investigation
<>U
Contact Following Entity for Eligibility or Benefit Information
<>FS
First Dollar Coverage, Single Service
<>FC
First Dollar Coverage, Applies to the Entire Plan
<>AA
Patient Reimbursement
<>H
Unlimited
<>8
Inactive - Pending Investigation
<>X
Health Care Facility
<>11
Active - Pending Receipt of Premium Payment
<>C
Deductible
<>3
Active - Services Capitated
<>S
Prior Year(s) History
<>V
Cannot Process
<>TB
Tiered Benefit
<>MC
Managed Care Coordinator
<>F
Limitations
<>6
Inactive
<>9
Coverage Never Activated
<>CB
Coverage Basis
<>Y
Spend Down
<>WV
Waiver
<>10
Inactive - Premium Payment Not Received
<>SB
Shared Benefit Limitation
<>I
Non-Covered

EDI Dictionary

SBI Specific Benefit Information

Elements

Element Details