ADDENDUM 6--ELIGIBILITY FOR A HEALTH PLAN

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The transaction selected for the eligibility for a health plan is ASC X12N 270/271 - Health Care Eligibility Inquiry and Response (004010X092).

A. Implementation Guide and Source

The source of the implementation guide for eligibility for a health plan transaction set is: Washington Publishing Company, 806 W. Diamond Ave., Suite 400, Gaithersburg, MD, 20878, Telephone 301- 590-9337, FAX: 301-869-9460. The website address is http://www.wpc-edi.com/hipaa/

B. Data Elements

Labels

Agency Qualifier Code

Amount Qualifier Code

Authorization Indicator Code

Benefit Coverage Level Code

Benefit Used or Available Amount

Birth Sequence Number

Communication Number Qualifier

Communication Number

Contact Function Code

Country Code

Coverage Level Code

Creation Date

Date Time Period Format Qualifier

Date/Time Qualifier

Dependent Additional Identification Text

Dependent Additional Identifier

Dependent Benefit Date

Dependent Birth Date

Dependent City Name

Dependent Communications Number

Dependent Contact Name

Dependent First Line Address

Dependent First Name

Dependent Gender Code

Dependent Identification Code

Dependent Last Name

Dependent Middle Name

Dependent Name Suffix

Dependent Postal Zip Code

Dependent Second Line Address

Dependent State Code

Dependent Trace Number

Description Text

Eligibility or Benefit Amount

Eligibility or Benefit Information

Eligibility or Benefit Percent

Entity Identifier Code

Entity Type Qualifier

File Creation Time

Follow-up Action Code

Free-Form Message Text

Handicap Indicator Code

Hierarchical Child Code

Hierarchical ID Number

Hierarchical Level Code

Hierarchical Parent ID Number

Hierarchical Structure Code

Identification Code Qualifier

Individual Relationship Code

Information Receiver Additional Address

Information Receiver Additional Identifier

Information Receiver Address

Information Receiver City

Information Receiver Contact Name

Information Receiver First Name

Information Receiver Identification Number

Information Receiver Last or Organization Name

Information Receiver Middle Name

Information Receiver Name Suffix

Information Receiver State

Information Receiver Trace Number

Information Receiver ZIP Code

Information Source Contact Name

Information Source Process Date

Insurance Eligibility Date

Insurance Type Code

Insured Indicator

Location Identification Code

Location Qualifier

Loop Identifier Code

Maintenance Reason Code

Maintenance Type Code

Network Services Code

Originating Company Identifier

Originating Company Secondary Identifier

Period Count

Plan Coverage Description Text

Plan Sponsor Name

Printer Carriage Control Code

Prior Authorization Number

Prior Authorization Text

Procedure Coding Method

Procedure Modifier

Product/Service ID Qualifier

Provider Address 1

Provider Address 2

Provider City

Provider Code

Provider Contact Name

Provider Contact Number

Provider First Name

Provider Identifier

Provider Last or Organization Name

Provider Middle Name

Provider Name Suffix

Provider Specialty Certification Code

Provider Specialty Code

Provider State

Provider Zip

Quantity Qualifier

Receiver Additional Identifier Description Text

Receiver Additional Identifier

Receiver Provider Additional Identifier Type Code

Receiver Provider Additional Identifier

Receiver Trace Number

Reference Identification Qualifier

Reject Reason Code

Relationship To Insured Code

Sample Selection Modulus

Service Type Code

Service Unit Count

Ship/Delivery or Calendar Pattern Code

Ship/Delivery Pattern Time Code

Source Additional Reference Identifier

Source City Name

Source Organization Name

Source Postal Zip Code

Source Primary Identification Number

Source State Code

Source Street Address

Spend Down Amount

Student Status Code

Subscriber Additional Identifier

Subscriber Additional Information Text

Subscriber Benefit Date

Subscriber Birth Date

Subscriber Card Issue Date

Subscriber City

Subscriber Contact Name

Subscriber Contact Phone Number

Subscriber First Address Line

Subscriber First Name

Subscriber Gender Code

Subscriber Identifier

Subscriber Last Name

Subscriber Middle Name

Subscriber Name Suffix

Subscriber Postal ZIP Code

Subscriber Second Address Line

Subscriber State

Time Period Qualifier

Trace Assigning Entity Additional Number

Trace Assigning Entity Number

Trace Number

Trace Type Code

Transaction Segment Count

Transaction Set Control Number

Transaction Set Identifier Code

Transaction Set Purpose Code

Transaction Type Code

Unit or Basis for Measurement Code

Valid Request Indicator Code

Value Added Network Trace Number