E1 Transaction: Eligibility Request
Transaction Header Segment
Mandatory in all cases
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
101-A1 | BIN Number | 610084 | M | |
102-A2 | Version/Release Number | D0 = Version D.0 | M | |
103-A3 | Transaction Code | E1 = Eligibility Verification | M | |
104-A4 | Processor Control Number | DRTXPROD | M | |
109-A9 | Transaction Count | 1 = One Occurrence | M | |
202-B2 | Service Provider ID Qualifier | 01 = National Provider Identifier (NPI) | M | |
201-B1 | Service Provider ID | 10-digit NPI | M | |
401-D1 | Date of Service | M | Fill Date, Format = CCYYMMDD | |
110-AK | Software Vendor/Certification ID | Three-digit software identification number with space fill | M |
Insurance Segment
Mandatory
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 04 = Insurance Segment | M | |
302-C2 | Cardholder ID | R |
Recipient Program ID Number
|
|
313-CD | Cardholder Last Name | O | Optional; must match if transmitted | |
301-C1 | Group ID |
|
R | For HTW cardholder IDs, enter ‘MEDICAID’ |
Patient Segment
Required
Field Number | Field Name | Value | Usage | Comment |
---|---|---|---|---|
111-AM | Segment Identification | 01 = Patient Segment | M | |
304-C4 | Date of Birth | R | Format = CCYYMMDD | |
305-C5 | Patient Gender Code |
|
R |