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X12 transaction guide · Healthcare and insurance

EDI 269 Health Care Benefit Coordination Verification

The X12 document used to transmit and respond to health care benefit coordination information, such as prior adjudication details, between payers.

Sent by
Health plan or payer
Received by
Another health plan or payer
Standard
ANSI ASC X12

What is an EDI 269?

The EDI 269 Health Care Benefit Coordination Verification is the ANSI X12 transaction set used to transmit and respond to health care benefit coordination information, such as claim identification, previous adjudication details and adjudication verification, from one health care payer to another.

When a patient is covered by more than one plan, coordination of benefits decides which plan pays first and how much the second plan pays. Exchanging adjudication details between payers prevents duplicate payments and gaps in coverage. It supports accurate secondary payments.

How the EDI 269 worksDiagram of the EDI 269 Health Care Benefit Coordination Verification. Health plan or payer sends it to another health plan or payer. It usually starts the exchange. It is usually followed by 997. Inside the ISA, GS and ST envelopes, X12 release 008010 requires, in the heading: BGN (Beginning Segment) and the required 1000 loop with N1 (Party Identification) and detail: the required 2000 loop with TRN (Trace). 2 optional loops are listed by their first segment.How the EDI 269 worksHealth Care Benefit Coordination Verification: who sends it, where it fits and what the standard marks required1 WHERE IT FITSUSUALLY FOLLOWSStarts the exchangeEDI 269SENDERHealth plan or payerRECEIVERAnother health plan orpayer997 or 999 acknowledgment back, if the partners agreeUSUALLY FOLLOWED BY997FunctionalAcknowledgment2 WHAT X12 RELEASE 008010 REQUIRESInterchange: sender and receiver IDsISA … IEAFunctional group, ID code HVGS … GETransaction set 269ST … SEHEADINGBGNBeginning SegmentRequired loop 1000 · repeats up to 2N1Party IdentificationDETAILRequired loop 2000 · repeats many timesTRNTrace+ 2 optional loops, starting with:NM1SVCBlue box: required loop. Optional loops are listed by the segment that starts them; when a loop is used, that first segment is required. Optional segmentsoutside loops are not drawn.Structure: required segments and loops in the X12 008010 listing for the 269. Your trading partner's implementation guide adds its own requirements.
How the EDI 269 worksDiagram of the EDI 269 Health Care Benefit Coordination Verification. Health plan or payer sends it to another health plan or payer. It usually starts the exchange. It is usually followed by 997. Inside the ISA, GS and ST envelopes, X12 release 008010 requires, in the heading: BGN (Beginning Segment) and the required 1000 loop with N1 (Party Identification) and detail: the required 2000 loop with TRN (Trace). 2 optional loops are listed by their first segment.How the EDI 269 worksHealth Care Benefit Coordination Verification:who sends it, where it fits and what thestandard marks required1 WHERE IT FITSUSUALLY FOLLOWSStarts the exchangeEDI 269SENDERHealth plan orpayerRECEIVERAnother healthplan or payer997 or 999 acknowledgment back, if the partnersagreeUSUALLY FOLLOWED BY997Functional Acknowledgment2 WHAT X12 RELEASE 008010 REQUIRESInterchange: sender and receiver IDs (ISA… IEA)Functional group, ID code HV (GS … GE)Transaction set 269 (ST … SE)HEADINGBGNBeginning SegmentRequired loop 1000 · repeats upto 2N1Party IdentificationDETAILRequired loop 2000 · repeatsmany timesTRNTrace+ 2 optional loops, starting with:NM1SVCBlue box: required loop. Optional loops are listedby the segment that starts them; when a loop isused, that first segment is required. Optionalsegments outside loops are not drawn.Structure: required segments and loops in the X12008010 listing for the 269. Your trading partner'simplementation guide adds its own requirements.

How to read this diagram: the top row shows who sends the 269, to whom, and which documents usually come before and after it. The lower part shows what X12 release 008010 itself requires: the envelopes around the 269 and the segments and loops the standard marks as required, area by area. Optional loops are listed by the segment that starts them rather than drawn in full. This is the standard's minimum, not a trading partner's requirement: each partner's implementation guide usually makes some optional loops mandatory, restricts the codes and may use a different release.

Expand diagram Download SVG

When it is used

  • Verifying how another payer adjudicated a claim
  • Coordinating payments between primary and secondary plans
  • Resolving coordination of benefits disputes

Where it fits in the document flow

This document 269 Health Care Benefit Coordination Verification
Usually followed by 997 Functional Acknowledgment

Structure

Mandatory segments in the 269 (X12 release 008010)

The segments X12 release 008010 marks as mandatory at their level, in order. Segments inside optional loops are needed only when the loop is used. This is the standard's requirement, not your trading partner's: each partner's implementation guide names the release it uses, adds the optional segments it requires and restricts the values. The requirement status comes from one published X12 reference listing and has not been checked against a second source.

  • ST
  • BGN
  • N1
  • TRN
  • NM1
  • SVC
  • SE

Practical example

The 269 in practice

A secondary health plan receives a claim for a patient also covered by a spouse's plan. It sends the primary plan a 269 asking how the claim was adjudicated. The primary plan responds with the amounts allowed and paid, and the secondary plan pays the remaining eligible amount.

Implementation

Implementation considerations for the 269

  • Protect patients' health information under applicable law.
  • Identify claims and members precisely between payers.
  • Follow the applicable coordination of benefits rules.
  • Check which transactions are mandated in your market.

How ECOM helps

Automate the 269 with ECOM

Industry

Healthcare

Secure B2B integration and file transfer for providers, suppliers, distributors and healthcare partners.

Solution

EDI Integration

Exchange X12 and EDIFACT documents with partners and integrate them directly with your ERP.

Solution

B2B Integration

Connect every customer, supplier, carrier and bank across EDI, API, file and portal channels.

More general questions about EDI are answered in the EDI FAQ.

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