Eligibility Codes

Eligibility System Status Codes

Code	Status Description
Not Found	Error codes are present. Eligibility record is not found.
Not Available	Error codes are present. Unavailable and unable to respond.
System Error	Error codes are present. The interface is causing an error.
Active with Restrictions	Eligibility benefit information returned with either a combination of active and inactive benefits or active and limiting benefit information.
Needs Review	Eligibility benefit information returned with either a combination active and inactive benefits or inactive and limiting benefit information
Inactive	Eligibility benefit information returned with inactive benefits
Active	Eligibility benefit information returned with active benefits

---

Eligibility Benefit Codes

Code	Benefit Description
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 of Data
X	Health Care Facility
Y	Spend Down"

---

Eligibility Error Codes

Code	Error Description
4	Authorized Quantity Exceeded
15	Required application data missing
33	Input Errors
35	Out of Network
41	Authorization/Access Restrictions
42	Unable to Respond at Current Time
43	Invalid/Missing Provider Identification
44	Invalid/Missing Provider Name
45	Invalid/Missing Provider Specialty
46	Invalid/Missing Provider Phone Number
47	Invalid/Missing Provider State
48	Invalid/Missing Referring Provider Identification Number
49	Provider is Not Primary Care Physician
50	Provider Ineligible for Inquiries
51	Provider Not on File
52	Service Dates Not Within Provider Plan Enrollment
53	Inquired Benefit Inconsistent with Provider Type
54	Inappropriate Product/Service ID Qualifier
55	Inappropriate Product/Service ID
56	Inappropriate Date
57	Invalid/Missing Date(s) of Service
58	Invalid/Missing Date-of-Birth
60	Date of Birth Follows Date(s) of Service
61	Date of Death Precedes Date(s) of Service
62	Date of Service Not Within Allowable Inquiry Period
63	Date of Service in Future
64	Invalid/Missing Patient ID
65	Invalid/Missing Patient Name
66	Invalid/Missing Patient Gender Code
67	Patient Not Found
68	Duplicate Patient ID Number
69	Inconsistent with Patient's Age
70	Inconsistent with Patient's Gender
71	Patient Birth Date Does Not Match That for the Patient on the Database
72	Invalid/Missing Subscriber/Insured ID
73	Invalid/Missing Subscriber/Insured Name
74	Invalid/Missing Subscriber/Insured Gender Code
75	Subscriber/Insured Not Found
76	Duplicate Subscriber/Insured ID Number
77	Subscriber Found, Patient Not Found
78	Subscriber/Insured Not in Group/Plan Identified
79	Invalid Participant Identification
80	No Response received - Transaction Terminated
97	Invalid or Missing Provider Address
98	Experimental Service or Procedure
AA	Authorization Number Not Found
AE	Requires Primary Care Physician Authorization
AF	Invalid/Missing Diagnosis Code(s)
AG	Invalid/Missing Procedure Code(s)
AO	Additional Patient Condition Information Required
CI	Certification Information Does Not Match Patient
E8	Requires Medical Review
IA	Invalid Authorization Number Format
MA	Missing Authorization Number
T4	Payer Name or Identifier Missing

---

Eligibility Alerts

Alert #	Alert Description
1	The payer's system is not available or did not respond in a timely manner. Possible causes are: The payer may be experiencing a system issue. The payer is not able to identify the patient or information receiver with the information provided.
2	The payer did not return the service type that was submitted in the request: {Service Type Description} ({Service Type Code}).
3	The payer returned a value for {Subscriber ID or Patient Name or Patient DOB or SSN} that does not match the value submitted in the request:
4	The payer did not return the Social Security Number that was submitted in the request.
5	The payer returned multiple copay amounts for the following service types submitted in the request: {Service Type Codes}
6	The payer returned only {Dental or Pharmacy or Vision or "Dental and Pharmacy"} benefit information.
7	Home Health Care - Episode
8	Hospice - Episode
9	Skilled Nursing Care - Episode
10	Skilled Nursing Care (Room and Board) - Episode
11	HSN Benefits are available.
12	Payer did not return { Submitted Service Type} { Submitted Coverage Level} {Deductible YTD or Deductible Maximum or Out of Pocket YTD or Out of Pocket Maximum}. Effective {Coverage Level} Benefits for service cannot be determined
13	The payer has returned notes. Please see below

---

Identification Code Qualifier

Code	Description
II	Standard Unique Health Identifier for each Individual in the United States Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of the Department of Health and Human Services may adopt a standard individual identifier for use in this transaction.
MI	Member Identification Number This code may only be used prior to the mandated use of code “II”. This is the unique number the payer or information source uses to identify the insured (e.g., Health Insurance Claim Number, Medicaid Recipient ID Number, HMO Member ID, etc.).