Medicare 271 Transaction Example Using The HETS Application EB 270/271 5010271Response Current

User Manual: EB 270/271

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Date of Last Revision: 06/10/2016 Page 1

Medicare 5010A1 271 Transaction Example using the HETS Application

Not all of the information presented in this example will be on every Medicare 271 response. This example is for illustrative purposes only and shows the

various eligibility information that a 271 response may contain, including Part A, Part B, SNF, Hospital, Preventive, Smoking Cessation, Blood Deductible,

Hospice, MSP, Home Health, Medicare Advantage, Part D, Inactive Periods, Rehabilitation, and Occupational, Physical, & Speech Therapies.

Note: The information in Table 1 is a representative example from the upcoming HETS R2016Q300 release.

Table 1: Medicare 5010A1 271 Transaction Example

271 Segment HETS Returned Values

ISA*00* *00* *ZZ*CMS *ZZ*SUBMITTERID *160130*0758*^*00501*111111111*0*P*|~

ISA06 = “CMS” plus spaces (will be 15 bytes)

ISA08 = Submitter ID plus spaces (will be 15 bytes)

GS*HB*CMS*SUBMITTERID*20160130*07580000*1*X*005010X279A1~

GS02 = “CMS”

GS03 = Submitter ID

ST*271*0001*005010X279A1~

N/A

BHT*0022*11*TRANSA*20160130*07582355~

N/A

HL*1**20*1~

N/A

NM1*PR*2*CMS*****PI*CMS~

NM101 = “PR”

NM102 = “2”

NM103 = “CMS”

NM108 = “PI”

NM109 = “CMS”

HL*2*1*21*1~

N/A

NM1*1P*2*IRNAME*****XX*1234567893~

NM101 = “1P”, “FA”, or “80”

HL*3*2*22*0~

N/A

TRN*2*TRACKNUM*ABCDEFGHIJ~

N/A

NM1*IL*1*LNAME*FNAME*M***MI*HICN~

NM109 = HICN

N3*ADDRESS LINE1*ADDRESS LINE2~

N/A

N4*CITY*ST*ZIPCODE~

N/A

DMG*D8*19400401*F~

N/A

DTP*307*RD8*20150927-20160430~

DTP03 = Date(s) of Service from the 270 inquiry

The following segments illustrate an Inactive (Alien, Deported, or Incarcerated) period.

N/A

EB*6**30~

N/A

DTP*307*RD8*20151101-20151103~

DTP03 = Part A and Part B Entitlement Inactive Date(s)

The following segment illustrates HETS supported Service Type Codes (STC) not covered by

Medicare

N/A

EB*I**41^54~

N/A

The following segment illustrates active or inactive Part D Coverage

N/A

Date of Last Revision: 06/10/2016 Page 2

271 Segment HETS Returned Values

EB*1**88~

EB01= Status of Coverage "1" or "6"

The following segments illustrate Part A Entitlement/Coverage

N/A

EB*1**30^10^42^45^48^49^69^76^83^A5^A7^AG^BT^BU^BV*MA~

EB03= "30" and applicable HETS supported Service Type Codes

EB04= "MA"

DTP*291*D8*20050401~

DTP03 = Entitlement and Termination Dates (where applicable)

The following segments illustrate Part A Deductible Financial Data

N/A

EB*C**30*MA**26*1288~

EB07 = Part A Base Deductible 2016

DTP*291*RD8*20160101-20161231~

DTP03= Calendar Year

EB*C**30*MA**26*1260~

EB07 = Part A Base Deductible 2015

DTP*291*RD8*20150101-20151231~

DTP03= Calendar Year

EB*C**30*MA**29*1288~

EB07 = Part A Base Deductible as Remaining 2016

DTP*291*RD8*20160101-20161231~

DTP03= Calendar Year

EB*C**30*MA**29*1260~

EB07 = Part A Base Deductible as Remaining 2015

DTP*291*RD8*20150101-20151231~

DTP03= Calendar Year

EB*C**30*MA**29*0~

EB07 = Part A Spell Deductible Remaining 2016

DTP*291*RD8*20160114-20160120~

DTP03 = Part A Spell DOEBA-DOLBA for Deductible Remaining

The following segments illustrate Part A “Free” Services

N/A

EB*C**42^45*MA**26*0~

EB07 = Part A Base Deductible is not applicable 2016

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*C**42^45*MA**26*0~

EB07 = Part A Base Deductible is not applicable 2015

DTP*292*RD8*20150101-20151231~

DTP03 = Calendar Year

The following segments illustrate Part A Hospital Days Base

To receive Hospital Data the 270 request MUST contain STC= 47,

48, 49, A5, A7 and/or AG

EB*B**30*MA**7*0~

EB07 = Part A Co-Payment per day (Fully Cov Days) 2016

HSD***DA**30*0~

HSD06 = "0" (Illustrates days exceeding 0)

HSD***DA**31*60~

HSD06 = "60" (Illustrates through day 60)

HSD*****26*1~

HSD06 = "1" (per Part A Spell)

DTP*435*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*B**30*MA**7*322~

EB07 = Part A Spell Daily Co-Payment Amount 2016

HSD***DA**30*60~

HSD06 = "60" (Illustrates days exceeding 60)

HSD***DA**31*90~

HSD06 = "90" (Illustrates through day 90)

HSD*****26*1~

HSD06 = "1" (per Part A Spell)

DTP*435*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*B**30*MA**7*0~

EB07 = Part A Co-Payment per day (Fully Cov Days) 2015

HSD***DA**30*0~

HSD06 = "0" (Illustrates days exceeding 0)

HSD***DA**31*60~

HSD06 = "60" (Illustrates through day 60)

HSD*****26*1~

HSD06 = "1" (per Part A Spell)

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271 Segment HETS Returned Values

DTP*435*RD8*20150101-20151231~

DTP03 = Calendar Year

EB*B**30*MA**7*315~

EB07 = Part A Spell Daily Co-Payment Amount 2015

HSD***DA**30*60~

HSD06 = "60" (Illustrates days exceeding 60)

HSD***DA**31*90~

HSD06 = "90" (Illustrates through day 90)

HSD*****26*1~

HSD06 = "1" (per Part A Spell)

DTP*435*RD8*20150101-20151231~

DTP03 = Calendar Year

The following segments illustrate Part A Hospital Days Remaining when no spell applies

To receive Hospital Data the 270 request MUST contain STC= 47,

48, 49, A5, A7 and/or AG

EB*B**30*MA**7*0~

EB07 = Part A Co-Payment per day (Fully Cov Days) 2016

HSD***DA**29*60~

HSD06 = "60" for Part A Spell Fully-Covered Days Remaining

HSD*****26*1~

HSD06 = "1" (per Part A Spell)

DTP*435*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*B**30*MA**7*322~

EB07 = Part A Spell Daily Co-Payment Amount 2016

HSD***DA**29*30~

HSD06 = "30" for Part A Spell Co-Payment Days Remaining

HSD*****26*1~

HSD06 = "1" (per Part A Spell)

DTP*435*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*B**30*MA**7*0~

EB07 = Part A Co-Payment per day (Fully Cov Days) 2015

HSD***DA**29*60~

HSD06 = "60" for Part A Spell Fully-Covered Days Remaining

HSD*****26*1~

HSD06 = "1" (per Part A Spell)

DTP*435*RD8*20150101-20151231~

DTP03 = Calendar Year

EB*B**30*MA**7*315~

EB07 = Part A Spell Daily Co-Payment Amount 2015

HSD***DA**29*30~

HSD06 = "30" for Part A Spell Co-Payment Days Remaining

HSD*****26*1~

HSD06 = "1" (per Part A Spell)

DTP*435*RD8*20150101-20151231~

DTP03 = Calendar Year

The following segments illustrate Hospital Days Remaining in a Part A Spell

To receive Spell Data the 270 request MUST contain STC= 47, 48,

49, A5, A7 and/or AG and spell must be present within 60 days of

search request date.

EB*B**30*MA**7*0~

EB07 = Part A Co-Payment per day (Fully Cov Days) 2016

HSD***DA**29*56~

HSD06 = Part A Spell Fully-Covered Days Remaining

HSD*****26*1~

HSD06 = "1" (per Part A Spell)

DTP*435*RD8*20160114-20160120~

DTP03 = Part A Spell DOEBA-DOLBA

EB*B**30*MA**7*322~

EB07 = Part A Spell Daily Co-Payment Amount 2016

HSD***DA**29*30~

HSD06 = Part A Spell Co-Payment Days Remaining

HSD*****26*1~

HSD06 = "1" (per Part A Spell)

DTP*435*RD8*20160114-20160120~

DTP03 = Part A Spell DOEBA-DOLBA

The following segments illustrate Part A SNF Days Base

To receive Skilled Nursing Facility Data the 270 request MUST

contain STC= AG

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271 Segment HETS Returned Values

EB*B**AG*MA**7*0~

EB07 = Part A SNF Co-Payment per day (Fully Cov Days) 2016

HSD***DA**30*0~

HSD06 = "0" (Illustrates days exceeding 0)

HSD***DA**31*20~

HSD06 = "20" (Illustrates through day 20)

HSD*****26*1~

HSD06 = "1" (per SNF Spell)

DTP*435*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*B**AG*MA**7*161~

EB07 = Part A Spell SNF Daily Co-Payment Amount 2016

HSD***DA**30*20~

HSD06 = "20" (Illustrates days exceeding 20)

HSD***DA**31*100~

HSD06 = "100" (Illustrates through day 100)

HSD*****26*1~

HSD06 = "1" (per SNF Spell)

DTP*435*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*B**AG*MA**7*0~

EB07 = Part A SNF Co-Payment per day (Fully Cov Days) 2015

HSD***DA**30*0~

HSD06 = "0" (Illustrates days exceeding 0)

HSD***DA**31*20~

HSD06 = "20" (Illustrates through day 20)

HSD*****26*1~

HSD06 = "1" (per SNF Spell)

DTP*435*RD8*20150101-20151231~

DTP03 = Calendar Year

EB*B**AG*MA**7*157.5~

EB07 = Part A Spell SNF Daily Co-Payment Amount 2015

HSD***DA**30*20~

HSD06 = "20" (Illustrates days exceeding 20)

HSD***DA**31*100~

HSD06 = "100" (Illustrates through day 100)

HSD*****26*1~

HSD06 = "1" (per SNF Spell)

DTP*435*RD8*20150101-20151231~

DTP03 = Calendar Year

The following segments illustrate Part A SNF Days Remaining when no spell applies

To receive Skilled Nursing Facility Data the 270 request MUST

contain STC= AG

EB*B**AG*MA**7*0~

EB07 = Part A SNF Co-Payment per day (Fully Cov Days) 2016

HSD***DA**29*20~

HSD06 = "20" for Part A Spell SNF Fully-Covered Days Remaining

HSD*****26*1~

HSD06 = "1" (per SNF Spell)

DTP*435*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*B**AG*MA**7*161~

EB07 = Part A Spell SNF Daily Co-Payment Amount 2016

HSD***DA**29*80~

HSD06 = "80" for Part A Spell SNF Co-Payment Days Remaining

HSD*****26*1~

HSD06 = "1" (per SNF Spell)

DTP*435*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*B**AG*MA**7*0~

EB07 = Part A SNF Co-Payment per day (Fully Cov Days) 2015

HSD***DA**29*20~

HSD06 = "20" for Part A Spell SNF Fully-Covered Days Remaining

HSD*****26*1~

HSD06 = "1" (per SNF Spell)

DTP*435*RD8*20150101-20151231~

DTP03 = Calendar Year

EB*B**AG*MA**7*157.5~

EB07 = Part A Spell SNF Daily Co-Payment Amount 2015

HSD***DA**29*80~

HSD06 = "80" for Part A Spell SNF Co-Payment Days Remaining

HSD*****26*1~

HSD06 = "1" (per SNF Spell)

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271 Segment HETS Returned Values

DTP*435*RD8*20150101-20151231~

DTP03 = Calendar Year

The following segments illustrate Part A SNF Spell Days Remaining in a Part A Spell

To receive Spell SNF Data the 270 request MUST contain STC= AG

and spell must be present within 60 days of search request date.

EB*B**AG*MA**7*0~

EB07 = Part A SNF Co-Payment per day (Fully Cov Days) 2016

HSD***DA**29*18~

HSD06 = Part A Spell SNF Fully-Covered Days Remaining

HSD*****26*1~

HSD06 = Per SNF Spell

DTP*435*RD8*20160414-20160420~

DTP03 = Part A Spell DOEBA-DOLBA

EB*B**AG*MA**7*161~

EB07 = Part A Spell SNF Daily Co-Payment Amount 2016

HSD***DA**29*80~

HSD06 = Part A Spell SNF Co-Payment Days Remaining

HSD*****26*1~

HSD06 = Per SNF Spell

DTP*435*RD8*20160414-20160420~

DTP03 = Part A Spell DOEBA-DOLBA

The following segments illustrate Part A Lifetime Reserve

To receive Lifetime Reserve Data the 270 request MUST contain

STC= 47, 48, 49, A5, A7 and/or AG.

EB*K**30*MA**32***DY*60~

EB10 = Part A Lifetime Reserve Base Days

EB*K**30*MA**33***DY*58~

EB10 = Part A Lifetime Reserve Remaining Days

EB*K**30*MA**7*644~

EB07 = Part A Co-Payment amount per day 2016

DTP*435*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*K**30*MA**7*630~

EB07 = Part A Co-Payment amount per day 2015

DTP*435*RD8*20150101-20151231~

DTP03 = Calendar Year

The following segments illustrate Part A Lifetime Psychiatric Limitation Data

To receive Lifetime Psychiatric Limitation Data the 270 request

MUST contain STC= A7. Submitters are only permitted to request

STC A7 on behalf of Psychiatric/Mental Health professionals and

institutions. Compliance will be monitored by CMS.

EB*K**A7*MA**32***DY*190~

EB10 = Part A Lifetime Psychiatric Base Days

EB*K**A7*MA**33***DY*180~

EB10 = Part A Lifetime Psychiatric Remaining Days

The following segment illustrates Part A Hospice Occurrence Count

Only returned if STC=45 is requested on 270

EB*D**45*MA**26***99*1~

EB10 = Part A Hospice Occurrence Count

The following segments illustrate Part B Entitlement/Coverage

N/A

EB*1**30^2^3^10^14^23^24^25^26^27^28^33^36^37^38^39^40^42^50^51^52^53^67^69^73^76^83^86^98

^A4^A6^A8^AD^AE^AF^AI^AJ^AK^AL^BF^BG^BT^BU^BV^DM^UC*MB~

EB03 = "30" and applicable HETS supported Service Type Codes

EB04 = "MB"

DTP*291*D8*20050401~

DTP03 = Entitlement and Termination Dates (where applicable)

The following segments illustrate Part B Plan Level Financial Data

N/A

EB*C**30*MB**23*166~

EB07 = Part B Base Deductible 2016

DTP*291*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*C**30*MB**23*147~

EB07 = Part B Base Deductible 2015

DTP*291*RD8*20150101-20151231~

DTP03 = Calendar Year

EB*C**30*MB**29*0~

EB07 = Part B Remaining Deductible 2016

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271 Segment HETS Returned Values

DTP*291*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*C**30*MB**29*0~

EB07 = Part B Remaining Deductible 2015

DTP*291*RD8*20150101-20151231~

DTP03 = Calendar Year

EB*A**30*MB**27**.2~

EB08 = Part B Plan Level Coinsurance2016

DTP*291*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*A**30*MB**27**.2~

EB08 = Part B Plan Level Coinsurance 2015

DTP*291*RD8*20150101-20151231~

DTP03 = Calendar Year

The following segments illustrate Part B” Free” Services Deductible

N/A

EB*C**5^42^67^AJ*MB**23*0~

EB07 = Part B Base Deductible is not applicable 2016

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*C**5^42^67^AJ*MB**23*0~

EB07 = Part B Base Deductible is not applicable 2015

DTP*292*RD8*20150101-20151231~

DTP03 = Calendar Year

The following segments illustrate Part B “Free” Services Coinsurance

N/A

EB*A**5^42^67^AJ*MB**27**0~

EB08 = Part B Co-Insurance for Part B is not applicable 2016

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar Year

EB*A**5^42^67^AJ*MB**27**0~

EB08 = Part B Co-Insurance for Part B is not applicable 2015

DTP*292*RD8*20150101-20151231~

DTP03 = Calendar Year

The following segments illustrate Benefit Level Financial Data for Part B HCPCS codes

Example of Multiple HETS Supported HCPCS codes requested.

EQ02 = 90670, G0106, G0117

EB*C***MB**23*0******HC|90670~

EB07 = Part B Plan Applicable Deductible Amount (Waived for this

service)

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar year of the date when the 270 request was received

EB*C***MB**23*0******HC|G0106~

EB07 = Part B Plan Applicable Deductible Amount (Waived for this

service)

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar year of the date when the 270 request was received

EB*C***MB**23*166******HC|G0117~

EB07 = Part B Plan Applicable Base Deductible Amount

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar year of the date when the 270 request was received

EB*C***MB**29*0******HC|G0117~

EB07 = Part B Remaining Deductible Amount (This will not be returned

if Base Deductible is waived) for this service

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar year of the date when the 270 request was received

EB*A***MB**27**0*****HC|90670~

EB08 = Part B Plan Applicable Coinsurance Amount (Waived for this

service)

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar year of the date when the 270 request was received

EB*A***MB**27**.2*****HC|G0106~

EB08 = Part B Plan Applicable Coinsurance Amount

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar year of the date when the 270 request was received

EB*A***MB**27**.2*****HC|G0117~

EB08 = Part B Plan Applicable Coinsurance Amount

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar year of the date when the 270 request was received

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271 Segment HETS Returned Values

The following segments illustrate beneficiary-specific eligibility for Part B Preventive Services.

EQ02 value must be requested on the 270

EB*D***MB*********HC|90670~(Preventive HCPCS Sample)

EB13 = Part B Preventive HCPCS Code

DTP*348*D8*20130101~

DTP03 = Next Eligible Date for Preventive Service

EB*D***MB*********HC|G0106~(Preventive HCPCS Sample)

EB13 = Part B Preventive HCPCS Code

DTP*348*D8*20140625~

DTP03 = Next Eligible Date for Preventive Service

EB*D***MB*********HC|G0117~(Preventive HCPCS Sample)

EB13 = Part B Preventive HCPCS Code

DTP*348*D8*20140625~

DTP03 = Next Eligible Date for Preventive Service

The following segments illustrate Part B Smoking Cessation Sessions.

NOTE: HETS will return either Number of Sessions Remaining or Next Eligible Date.

Only returned if STC=67 is requested on 270

EB*F**67*MB**22***VS*8~

EB10 = Part B Base Number of Smoking Cessation Sessions

HSD*VS*6***29~ (See note above)

HSD03 = Number of Smoking Cessation Sessions Remaining

OR

N/A

DTP*348*D8*20160101~ (See note above)

DTP03 = Next Eligible Date for Smoking Cessation if all sessions used

The following segments illustrate Part B Therapy Benefit Detail

Only returned if Part B STC=AD, AE or AF is requested on 270

EB*D**AD*MB***1345~

EB03 = AD for Occupational Therapy, EB07= Therapy Amount Used

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar Year

MSG*USED AMOUNT~

N/A

EB*D**AD*MB***200~

EB03 = AD for Occupational Therapy, EB07= Therapy Amount Used

DTP*292*RD8*20150101-20151231~

DTP03 = Calendar Year

MSG*USED AMOUNT~

N/A

EB*D**AE*MB***0~

EB03 =AE for Physical/Speech Therapy, EB07= Therapy Amount Used

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar Year

MSG*USED AMOUNT~

N/A

EB*D**AE*MB***0~

EB03 =AE for Physical/Speech Therapy, EB07= Therapy Amount Used

DTP*292*RD8*20150101-20151231~

DTP03 = Calendar Year

MSG*USED AMOUNT~

N/A

The following segments illustrate Part B Rehabilitation Benefit Detail

Only returned if Part B STC=BF or BG is requested on 270

EB*F**BF*MB**29***CA*36~

EB10 = Number of Pulmonary Rehabilitation Sessions remaining

MSG*Professional~

N/A

EB*F**BF*MB**29***CA*36~

EB10 = Number of Pulmonary Rehabilitation Sessions remaining

MSG*Technical~

N/A

EB*F**BG*MB*****99*0~

EB10 = Number of Cardiac Rehabilitation Sessions used

MSG*Professional~

N/A

EB*F**BG*MB*****99*0~

EB10 = Number of Cardiac Rehabilitation Sessions used

MSG*Technical~

N/A

EB*F**BG*MB*****99*15~

EB10 = Number of Intensive Cardiac Rehabilitation Services Used only

if MSG01 = Intensive Cardiac Rehabilitation

Date of Last Revision: 06/10/2016 Page 8

271 Segment HETS Returned Values

MSG*Intensive Cardiac Rehabilitation – Professional~

N/A

EB*F**BG*MB*****99*15~

EB10 = Number of Intensive Cardiac Rehabilitation Services Used only

if MSG01 = Intensive Cardiac Rehabilitation

MSG*Intensive Cardiac Rehabilitation – Technical~

N/A

The following segments illustrate Home Health (Cert /Recert dates each limited to 10 occurrences)

Only returned if Part A/B STC=42 is requested on 270

EB*X**42***26~

N/A

DTP*472*RD8*20150522-20150929~

DTP03 = Home Health Period Start & End Dates

DTP*193*D8*20150522

DTP03 = Home Health Period DOEBA

DTP*194*D8*20150929

DTP03 = Home Health Period DOLBA

LS*2120~

N/A

NM1*PR*2*ORGNAME*****PI*CONTR~

NM103 = Home Health Contractor Name NM109 = Home Health

Contractor Number

NM1*1P*2******XX*1234567890~

NM109 = Home Health Service Provider NPI

LE*2120~

N/A

EB*X************HC|G0180~

EB13 = Home Health Certification HCPC

DTP*193*D8*20150521~

DTP03 = Home Health Certification Start Date

EB*X************HC|G0179~

EB13 = Home Health Recertification HCPC

DTP*193*D8*20150917~

DTP03 = Home Health Recertification Date

DTP*193*D8*20150719~

DTP03 = Home Health Recertification Date

The following segments illustrate Part A Hospice Episodes

Only returned if Part A STC=45 is requested on 270

EB*X**45*MA**26~

N/A

DTP*292*RD8*20151115-20151205~

DTP03 = Hospice Period Date(s)

MSG*Revocation Code - 1~

MSG01 = “Revocation Code “ + Hospice Revocation Code

LS*2120~

N/A

NM1*1P*2******XX*1234567890~

NM109 = Hospice Provider NPI

LE*2120~

N/A

The following segments illustrate Part B ESRD data

Only returned if Part B STC=14 or 15 is requested on 270

EB*D**14*MB~

EB03 = 14 for Dialysis performed at home or in an outpatient facility

DTP*356*D8*20110601~

DTP03 = ESRD Dialysis Method Start Date

DTP*096*D8*20130105~

DTP03 = Kidney Transplant Hospital Discharge Date

OR

N/A

EB*D**15*MA~

EB03 = 15 for Dialysis performed as a part of an Inpatient stay

DTP*356*D8*20110601~

DTP03 = ESRD Dialysis Method Start Date

DTP*096*D8*20130105~

DTP03 = Kidney Transplant Hospital Discharge Date

The following segments illustrate Blood Deductible Data

Only returned if STC=10 is requested on 270

EB*E**10***23***DB*3~

EB10 = Number of Fully Covered Units

HSD*FL*2***29~

HSD02 = Number of Units Remaining

Date of Last Revision: 06/10/2016 Page 9

271 Segment HETS Returned Values

DTP*292*RD8*20160101-20161231~

DTP03 = Calendar year

EB*E**10***23***DB*3~

EB10 = Number of Fully Covered Units

HSD*FL*1***29~

HSD02 = Number of Units Remaining

DTP*292*RD8*20150101-20151231~

DTP03 = Calendar year

The following segments illustrate Part D Enrollment

N/A

EB*R**88*OT~

N/A

REF*18*S0000 999~

REF02 = Part D Contract Number + “ “ + PBP Number

DTP*292*D8*20130101~

DTP03 = Part D Plan Enrollment Date(s)

LS*2120~

N/A

NM1*PR*2*ORGNAME~

NM103 = Part D Contract Name

N3*ADDRESSLINE1*ADDRESSLINE2~

N301/N302 = Part D Contract Address

N4*CITY*ST*ZIPCODE~

N401/N402/N403 = Part D Contract City/State/ZIP

PER*IC**TE*AAABBBCCCC*UR*www.website.com~

PER04 = Part D Plan Telephone Number

PER06 = Contract Website Address

LE*2120~

N/A

The following segments illustrate Part C MCO (Medicare Advantage) enrollment

N/A

EB*R**30*IN~

EB04 = MCO Contract Type (HMO, PPO, Indemnity, etc.)

REF*18*H0000 999~

REF02 = MCO Contract Number +” “ + PBP Number

DTP*290*D8*20090101~

DTP03 = MCO Plan Enrollment Date(s)

MSG*MCO Bill Option Code- C~

MSG01 = “MCO Bill Option Code –“ +” ” + Bill Option Code

LS*2120~

N/A

NM1*PRP*2*ORGNAME~

NM103 = MCO Contract Name

N3*ADDRESSLINE1*ADDRESSLINE2~

N301/N302 = MCO Contract Address

N4*CITY*ST*ZIPCODE~

N401/N402/N403 = MCO Contract City/State/ZIP

PER*IC**TE*AAABBBCCCC*UR*www.website.com~

PER04 = MCO Plan Telephone Number

PER06 = MCO Plan Website Address

LE*2120~

N/A

The following segments illustrate MSP Enrollment

N/A

EB*R**30*13~

EB04 = MSP Insurance Type Code

REF*IG*POLICYNUMBER~

REF02 = Insurance Policy Number

DTP*290*RD8*20130701-20160401~

DTP03 = MSP Effective Date(s)

LS*2120~

N/A

NM1*PRP*2*ORGNAME~

NM103 = MSP Name

N3*ADDRESSLINE1*ADDRESSLINE2~

N301/N302 = MSP Insurance Address

N4*CITY*ST*ZIPCODE~

N401 = MSP City, N402=MSP State, N403=MSP Zip

LE*2120~

N/A

The following segments illustrate the end of a transaction.

N/A

Date of Last Revision: 06/10/2016 Page 10

271 Segment HETS Returned Values

SE*233*0001~

N/A

GE*1*1~

N/A

IEA*1*111111111~

N/A