X12 269 — Health Care Benefit Coordination Verification

The 269 documents the coordination-of-benefits verification across multiple health payers for a single insured: priority order, coverage periods.

Purpose

The 269 is used in Coordination of Benefits (COB) — situations where an insured has multiple coverages (primary + secondary, e.g., employer plan + spouse plan, Medicare + Medigap). It carries the list of plans, the primary / secondary attribution, effective periods, and applicable coordination rules.

It is typically used at enrollment or before a high-cost service to avoid double-payments. Acknowledged by 997. The 269 feeds claim adjudication processing — a multi-payer 837 must present payers in the validated priority order.

Envelope structure

The 269 travels within the three X12 envelope levels (ISA/IEA, GS/GE with functional group HV, and ST/SE). Didactic example in release 004010:

ISA*00*          *00*          *ZZ*PROVIDERCO    *ZZ*PAYER1         *260514*1800*U*00401*000000269*0*P*>~
GS*HV*PROVIDERCO*PAYER1*20260514*1800*1*X*004010~
ST*269*0001~
BGN*00*HV-2026-0042*20260514~
NM1*IL*1*DOE*JANE*A***MI*MEM-12345~
DMG*D8*19850712*F~
LX*1~
N1*PR*PAYER ALPHA*PI*PAY-A~
REF*ZZ*PRIMARY~
DTM*RT*20260101~
DTM*RT*20261231~
LX*2~
N1*PR*PAYER BETA*PI*PAY-B~
REF*ZZ*SECONDARY~
DTM*RT*20260101~
DTM*RT*20261231~
SE*13*0001~
GE*1*1~
IEA*1*000000269~

Common segments

• Header — ST, BGN.
• Insured — NM1*IL (Insured Patient), DMG.
• Plans — repeated LX loop per plan: N1*PR (Payer), REF*ZZ (PRIMARY/SECONDARY/TERTIARY), DTM*RT (effective period).
• COB rules — MSG or LQ for governing rules (Birthday Rule, custody-based, NAIC standard).
• Summary — SE.

Common pitfalls

• Birthday Rule: for a child covered by 2 parents, the NAIC Birthday Rule designates as primary the parent whose birthday (month/day, not year) falls first in the year — a 269 that ignores it mis-ranks priority.
• Medicare Secondary Payer (MSP): for an active senior over 65 with a large (over 20 employees) employer group plan, Medicare is secondary; a 269 that puts Medicare primary violates MSP regulations.
• Period overlap: an insured may hold 2 simultaneous plans with partially overlapping dates; the 269 must reflect exact dates per plan — a mis-captured overlap triggers double-payment.

Related transactions

• 270
• 271
• 834
• X12 — Hub

Documentation

The code 269 and the name Health Care Benefit Coordination Verification are public and listed on x12.org/products/transaction-sets. The complete structure of loops, qualifiers and code lists is distributed by DISA via the proprietary Implementation Guides (TR3). ediverse.io covers only public concepts, the envelope and didactic examples.