Use the appropriate loop either 2110C or 2110D for subscriber or dependent. EB01 will use qualifier B for copayment, EB02 will need the appropriate qualifier from the list on page 221, EB03 can either be service type code 1 or the appropriate service type code from the listing on pages 221 - 226. EB04 will be the Insurance Type Code such as C1 for Commercial Insurance, EB05 can be used as free form if the information is available. EB06 is the Time Period Qualifier and might be 27 Visit then finally you'll use EB07 to indicate a Monetary or EB08 to indicate a Percent copayment.
The remaining EB segment would be included as appropriate with one caveat, if EB09 or EB10 must be passed along the other also must be present. Robert C. Pozniak Third Party Liability Operations NYS Department of Health (518) 485-0037 phone (518) 402-0061 fax [EMAIL PROTECTED] ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request.
