Eligibility Codes

Eligibility System Status Codes

CodeStatus Description
Not FoundError codes are present. Eligibility record is not found.
Not AvailableError codes are present. Unavailable and unable to respond.
System ErrorError codes are present. The interface is causing an error.
Active with RestrictionsEligibility benefit information returned with either a combination of active and inactive benefits or active and limiting benefit information.
Needs ReviewEligibility benefit information returned with either a combination active and inactive benefits or inactive and limiting benefit information
InactiveEligibility benefit information returned with inactive benefits
ActiveEligibility benefit information returned with active benefits

Eligibility Benefit Codes

CodeBenefit Description
1Active Coverage
2Active - Full Risk Capitation
3Active - Services Capitated
4Active - Services Capitated to Primary Care Physician
5Active - Pending Investigation
7Inactive - Pending Eligibility Update
8Inactive - Pending Investigation
CBCoverage Basis
DBenefit Description
GOut of Pocket (Stop Loss)
JCost Containment
LPrimary Care Provider
MPre-existing Condition
MCManaged Care Coordinator
NServices Restricted to Following Provider
ONot Deemed a Medical Necessity
PBenefit Disclaimer
QSecond Surgical Opinion Required
ROther or Additional Payor
SPrior Year(s) History
TCard(s) Reported Lost/Stolen
UContact Following Entity for Eligibility or Benefit Information
VCannot Process
WOther Source of Data
XHealth Care Facility
YSpend Down"

Eligibility Error Codes

CodeError Description
4Authorized Quantity Exceeded
15Required application data missing
33Input Errors
35Out of Network
41Authorization/Access Restrictions
42Unable to Respond at Current Time
43Invalid/Missing Provider Identification
44Invalid/Missing Provider Name
45Invalid/Missing Provider Specialty
46Invalid/Missing Provider Phone Number
47Invalid/Missing Provider State
48Invalid/Missing Referring Provider Identification Number
49Provider is Not Primary Care Physician
50Provider Ineligible for Inquiries
51Provider Not on File
52Service Dates Not Within Provider Plan Enrollment
53Inquired Benefit Inconsistent with Provider Type
54Inappropriate Product/Service ID Qualifier
55Inappropriate Product/Service ID
56Inappropriate Date
57Invalid/Missing Date(s) of Service
58Invalid/Missing Date-of-Birth
60Date of Birth Follows Date(s) of Service
61Date of Death Precedes Date(s) of Service
62Date of Service Not Within Allowable Inquiry Period
63Date of Service in Future
64Invalid/Missing Patient ID
65Invalid/Missing Patient Name
66Invalid/Missing Patient Gender Code
67Patient Not Found
68Duplicate Patient ID Number
69Inconsistent with Patient's Age
70Inconsistent with Patient's Gender
71Patient Birth Date Does Not Match That for the Patient on the Database
72Invalid/Missing Subscriber/Insured ID
73Invalid/Missing Subscriber/Insured Name
74Invalid/Missing Subscriber/Insured Gender Code
75Subscriber/Insured Not Found
76Duplicate Subscriber/Insured ID Number
77Subscriber Found, Patient Not Found
78Subscriber/Insured Not in Group/Plan Identified
79Invalid Participant Identification
80No Response received - Transaction Terminated
97Invalid or Missing Provider Address
98Experimental Service or Procedure
AAAuthorization Number Not Found
AERequires Primary Care Physician Authorization
AFInvalid/Missing Diagnosis Code(s)
AGInvalid/Missing Procedure Code(s)
AOAdditional Patient Condition Information Required
CICertification Information Does Not Match Patient
E8Requires Medical Review
IAInvalid Authorization Number Format
MAMissing Authorization Number
T4Payer Name or Identifier Missing

Eligibility Alerts

Alert #Alert Description
1The 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.
2The payer did not return the service type that was submitted in the request: {Service Type Description} ({Service Type Code}).
3The 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:
4The payer did not return the Social Security Number that was submitted in the request.
5The payer returned multiple copay amounts for the following service types submitted in the request: {Service Type Codes}
6The payer returned only {Dental or Pharmacy or Vision or "Dental and Pharmacy"} benefit information.
7Home Health Care - Episode
8Hospice - Episode
9Skilled Nursing Care - Episode
10Skilled Nursing Care (Room and Board) - Episode
11HSN Benefits are available.
12Payer 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
13The payer has returned notes. Please see below

Identification Code Qualifier

IIStandard 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.
MIMember 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.).