271 Health Care Eligibility Benefit Inquiry and Response

270/271 Health Care Eligibility Benefit Inquiry and Response ASC x12N Version 004010x092A1 IBC/KHPE 270/271 Companion Guide V0.1 Rev. 08.22.03 -1- ...
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270/271 Health Care Eligibility Benefit Inquiry and Response ASC x12N Version 004010x092A1

IBC/KHPE 270/271 Companion Guide V0.1 Rev. 08.22.03

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Disclaimer This Health Plan Companion Guide to EDI Transactions (the “Companion Guide”) provides Health Plan’s trading partners with guidelines for submitting electronic batch transactions. Because the HIPAA ASC X12N Implementation Guides require transmitters and receivers to make certain determinations/elections (e.g., whether, or to what extent, situational data elements apply), this Companion Guide documents those determinations, elections, assumptions, or data issues that are permitted to be specific to Health Plan’s business processes when implementing the HIPAA ASC X12N 4010 Implementation Guides. This Companion Guide does NOT replace the HIPAA ASC X12N Implementation Guides, nor does it attempt to amend any of the requirements of the Implementation Guides, or impose any additional obligations on trading partners of Health Plan that are not permitted to be imposed by the HIPAA Standards for Electronic Transactions. This document provides information on Health Plan specific codes and situations that are within the parameters of the HIPAA Administrative Simplification rules. Readers of this Companion Guide should be acquainted with the HIPAA Implementation Guides, their structure, and content. This Companion Guide provides supplemental information to the Trading Partner Agreement that exists between Health Plan and its trading partners. Trading partners should refer to the Trading Partner Agreement for guidelines pertaining to Health Plan’s legal conditions surrounding the implementation of the EDI transactions and code sets. However, trading partners should refer to this Companion Guide for information on Health Plan’s business rules or technical requirements regarding the implementation of HIPAA-compliant EDI transactions and code sets. Nothing contained in this Companion Guide is intended to amend, revoke, contradict, or otherwise alter the terms and conditions of the Trading Partner Agreement. If there is an inconsistency between the terms of this Companion Guide and the terms of the Trading Partner Agreement, the terms of the Trading Partner Agreement will govern. If there is an inconsistency between the terms of this Companion Guide and any terms of one of the Implementation Guides, the relevant Implementation Guide will govern with respect to HIPAA edits, and this Companion Guide will control with respect to business edits.

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Table of Contents

270 Eligibility Request Transaction Overview of Document

3

General Information

4

Transmission Size and Type

4

Blue Exchange

5

Contact Information

5

270 Data Elements

5

271 Eligibility Response Transaction Overview of Document

11

General Information

11

Transmission Size and Type

11

Blue Exchange

12

Contact Information

12

271 Data Elements

12

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270 Health Care Eligibility Benefit Inquiry Overview of Document This guide is to be used as a supplement to the 270/271 Health Care Eligibility Benefit Inquiry Implementation Guide, version 004010x092A1. It should be used as a reference when processing eligibility requests for Independence Blue Cross and Keystone Health Plan East (hereinafter referred to as IBC/KHPE). In addition, transactions for members of other Blue Cross Plans can be submitted to IBC/KHPE. This process, known as Blue Exchange, is described in Section 4.0. The purpose of this document is to outline IBC/KHPE processes for handling the 270/271 Health Care Eligibility Benefit Implementation Guide (hereinafter referred to as the 270 or 271), and to delineate specific data requirements where this option is available within the 4010A1 Implementation Guide. This Companion Document does not add, delete or change the name of any data element that is specified in the Implementation Guide. However, in order to meet the business objectives, it does recommend a number of conventions that are intended to clarify and standardize the usage of specific data elements. TOP

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General Information This transaction set is used to inquire about the eligibility/benefits associated with a subscriber’s (or dependent’s) health plan coverage. The Information Source is a Health Plan (IBC/KHPE) and the Information Receiver is a Provider organization. The 270 transaction will be used to request eligibility information for a specific patient. That patient may be identified in the 270 as a subscriber or as a dependent. Per the HIPAA implementation guide, the maximum set of fields that that an Information Source can require for look-up are: • •

Subscriber: Member ID, patient first name, last name and date of birth Dependent: Subscriber member ID, patient first name, last name and date of birth

Ideally, IBC/KHPE would prefer to receive all of the data elements listed above. However, IBC/KHPE will conduct the search using any of the required data element combinations prescribed by the standard, specifically stated in Section 1.3.8 - Search Options. For the 270 transaction, if a service date is not provided, IBC/KHPE will use the current as the requested date of service. TOP

Transmission Size and Type Real time ANSI X12 270 Health Care Eligibility Benefit Inquiry, as defined in the HIPAA Implementation Guide, is a real time transaction containing an inquiry for no more than 1 patient. The Information Receiver, or their electronic intermediary, will send the 270 transaction to the Information Source and will remain connected while the Information Source processes the transaction and returns a response. This document considers a real time transaction to be a single transaction that contains a single inquiry for a single patient in a single envelope. As such, there will be one and only one of each of the following segments: ISA, GS, ST, SE, GE, IEA. TOP

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Blue Exchange The Blue Exchange process (Inter-Blue Plan Inquiries) enables providers to request eligibility information for a member of another Blue Cross plan by submitting a 270 to IBC/KHPE. To ensure that the 270 reaches the plan holding the membership data, a valid alpha prefix must precede the Member’s identification number; e.g. XYZ123456789. In addition, providers can request eligibility for Federal employees (FEP) via Blue Exchange. Federal employees are identified by a Member ID that begins with the letter R and is followed by 8 numeric characters; e.g. R12345678. TOP

Contact Information The 271 response transaction will contain contact information within the PER segment of the transaction. This information will be populated from the system of the plan that processed the response. Trading Partners are to use this information if they have questions or concerns regarding the 271 response. TOP

270 Data Elements The following pages identify the recommended usage of the data elements when the trading partner submits 270 transactions to IBC/KHPE. Additional information about the data elements or HIPAA requirements can be found within the ASCX12N Health Care Eligibility Benefits Inquiry and Response Implementation Guide. This does not represent a specification document. All trading partners should refer to the standard implementation guide for the correct formatting of a complete 270. TOP

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Segment: Loop: Level: Usage: Notes:

BHT Beginning of a Hierarchical Transaction Detail Required Due to IBC/KHPE business practices, this information is needed.

Data Element Summary Ref Des Element Name BHT02 Transaction Set Purpose Code

Element Note Enter code value: 13 (Request)

TOP

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Segment: Loop: Level: Usage: Notes:

NM1 Information Source Name

2100 A Detail Required Due to IBC/KHPE business practices, this information is needed.

Data Element Summary Ref Des Element Name NM101 Entity Identifier Code NM108 NM109

Identification Code Qualifier Identification Code

Element Note Enter code value: PR (Payer) Enter code value: NI (National Association of Insurance Commissioners (NAIC) Identification) Enter code value: 54704

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Segment: Loop: Level: Usage: Notes:

NM1 Information Receiver Name

2100 B Detail Required Due to IBC/KHPE business practices, this information is needed.

Data Element Summary Ref Des Element Name NM101 Entity Identifier Code NM108 NM109

Identification Code Qualifier Identification Code

Element Note Enter code value: Facility Provider – FA Professional Provider – 1P Enter code value: PI (Federal Taxpayer’s Identification Number) Enter value: Federal Tax Identification Number

TOP

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Segment: Loop: Level: Usage: Notes:

NM1 Subscriber Name

2100 C Detail Required Due to IBC/KHPE business practices, this information should be supplied when available.

Data Element Summary Ref Des Element Name NM108 Identification Code Qualifier NM109 Identification Code

Element Note Enter code value: MI (Member Identification) Enter value: Member Identification Number from ID card Examples: IBC – QCB123456789 KHPE – YXH987654321 Blue Exchange (Blue Plans) – XYZ123456789 Blue Exchange (FEP) – R12345678

For Dependent Inquiries: Segment: Loop: Level: Usage: Notes:

NM1 Dependent Name

2100 D Detail Required Due to IBC/KHPE business practices, this information should be supplied when available

Data Element Summary Ref Des Element Name NM103 Dependent Last Name NM104

Element Note

Dependent First Name

TOP

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Segment: Loop:

EQ Subscriber Eligibility or Benefit Inquire Information

2110 C 2110 D Detail Required IBC/KHPE will process 1 EQ loop only

Level: Usage: Notes: Data Element Summary Ref Des Element Name EQ04

Insurance Type Code

Element Note All code values will be accepted. Code value:MC – Medicaid will trigger a search of Family Planning specific eligibility

TOP

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271 Health Care Eligibility Benefit Response Overview of Document This guide is to be used as a supplement to the 271 Health Care Eligibility Benefit Response Implementation Guide, version 4010A1A1A1. It should be used to process eligibility responses for Independence Blue Cross and Keystone Health Plan East (hereinafter referred to as IBC/KHPE). The purpose of this document is to outline IBC/KHPE processes for handling the 270/271 Health Care Eligibility Response Implementation Guide (hereinafter referred to as the 271), and to delineate specific data requirements where that option is available within the 4010A1A1 Implementation Guide. This Companion Document does not add, delete or change the name of any data element that is specified in the Implementation Guide. However, in order to meet the business objectives, it does recommend a number of conventions that are intended to clarify and standardize the usage of specific data elements. TOP

General Information This transaction set is used to respond to eligibility/benefits inquiries (270’s) associated with a subscriber’s (or dependent’s) health plan coverage. The Information Source is a Health Plan (IBC/KHPE) and the Information Receiver is a provider organization. This 271 eligibility response will include: Eligibility Status, eligibility begin/end dates, coverage description, group number, PCP/specialist/ER copayment, Primary Care Physician (PCP) and capitated provider information. TOP



Transmission Size and Type Real time ANSI X12 271 Health Care Eligibility Response: IBC’s real-time response transaction will contain information for only one patient. As such, there will be one and only one of each of the following segments: ISA, GS, ST, SE, GE, IEA. TOP

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Blue Exchange The IBC eligibility inquiry process allows for the submission of 270’s for members of other Blue Cross plans. IBC forwards these 270’s to the plan holding the membership data (known as the Control Plan) through a process known as Blue Exchange. The provider should be aware that the 271 response transactions sent by another Blue Cross plan could vary in format from the standard IBC response. Thus, providers must be able to handle any HIPAA compliant Segment/Data Element listed in the 271 4010A1 Implementation Guide. Providers operating in real-time environments must be aware that although IBC is able to respond in a real-time manner, other Blue plans may not. If a response cannot be provided within 60 seconds, IBC will respond with a 271 AAA transaction, which will contain the Control Plan’s contact information within the Information Source PET segment. TOP

Contact Information The 271 transaction will contain contact information directing the trading partner as to who they can contact if they have questions regarding the response they received on the 271 transaction. This information will be available in the Information Source Contact (PER) segment. 271 transactions may contain different contact information; this information is provided by the plan that processes the request. TOP

271 Data Elements The following pages clarify carrier specific, situational and optional data elements returned within the IBC/KHPE 271 response transaction. The ASCX12N Health Care Eligibility Benefits Inquiry and Response Implementation Guide should be consulted for a complete overview of the 271 response transaction. TOP

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Segment: Loop: Level: Usage: Notes:

NM1 Information Source Name

2100 A Detail Required Due to IBC/KHPE business practices, this information is provided.

Data Element Summary Ref Des Element Name Element Note NM101 Entity Identification Code Enter code value: PR (Payer) HL-1 NM102 Entity Type Qualifier Expect Code value: 2 (Non Person Entity) NM103 NM108 NM109

Last Name or Organization Name Identification Code Qualifier Primary Identification

Expect value: Independence Blue Cross Expect value: NI (National Association of Insurance (NAIC) Commissioners) Expect value: 54704

Note: 271 response transactions emanating from other Blue Cross Plans (i.e. Blue Exchange) could contain other HIPAA compliant data. TOP

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Segment: Loop: Level: Usage: Notes:

NM1 Information Receiver Name

2100 B Detail Required Due to IBC/KHPE business practices, this information is provided.

Data Element Summary Ref Des Element Name NM101 Entity Identifier Code

Element Note Expect code value: 1P (Provider)

NM102

Entity Type Qualifier

Expect value: 2 (Non Person Entity)

NM108

Identification Code Qualifier Identification Code

Expect value: PI (Payer Identification)

NM109

Expect value: Payer’s Federal Tax Identification Number

Note: 271 response transactions emanating from other Blue Cross Plans (i.e. Blue Exchange) could contain other HIPAA compliant data. TOP

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Segment: Loop: Level: Usage: Notes:

NM1

Subscriber Name

2100 C Detail Required Due to IBC/KHPE business practices, this information is provided.

Data Element Summary Ref Des Element Name Element Note NM101 Entity Identification Code Expect value: IL (Insured or Subscriber) NM102

Entity Type Qualifier

Expect value: 1

NM108

Identification Code Qualifier Identification Code

Expect value: MI (Member Identification Qualifier)

NM109

(Person)

Expect value: Member Identification Number

Note: 271 response transactions emanating from other Blue Cross Plans (i.e. Blue Exchange) could contain other HIPAA compliant data. TOP

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Segment: Loop: Level: Usage: Notes:

REF Subscriber / Dependent Additional Identification

2100 C 2100 D Detail Situational Due to IBC/KHPE business practices, this information is provided.

Data Element Summary Ref Des Element Name REF01 Reference Identification Qualifier REF02

Reference Identification

Element Note Expect value: 6P (Group Number) Expect IBC/KHPE Group / Account Number

Note: 271 response transactions emanating from other Blue Cross Plans (i.e. Blue Exchange) could contain other HIPAA compliant data.

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Segment: Loop: Level: Usage: Notes:

DTP Subscriber Date

2100 C 2100 D Detail Required Due to IBC/KHPE business practices, this information is provided.

Data Element Summary Ref Des Element Name DTP01 Date Time Qualifier

DTP02 DTP03

Element Note Expect value(s): 356 (Eligibility Begin) 357 (Eligibility End) 472 (Date of Service) Date Time Period Format Expect value: Qualifier D8 CCYYMMDD RD8 CCYYMMDD-CCYYMMDD Date Time Period Expect value: Eligibility Begin Date Eligibility End Date Date of Service

Note: 271 response transactions emanating from other Blue Cross Plans (i.e. Blue Exchange) could contain other HIPAA compliant data. TOP

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Segment: Loop: Level: Usage: Notes:

DTP Subscriber Eligibility / Benefit Date

2110 C Detail Required If no date is provided to IBC/KHPE, its business practices will provide a blank DTP back to the subscriber, the Primary Care Physician is considered active. When a date is provided to IBC/KHPE, its business practices will provide the actual active date of a Primary Care Physician.

Data Element Summary Ref Des Element Name DTP01 Date / Time Qualifier DTP02 DTP03

Element Note Non-HMO Lines of Business: Field not populated HMO: Expect value 295 (Primary Care Provider) Date Time Period Format Expect value D8 (CCYYMMDD) Qualifier Date Time Period HMO: PCP Effective Date

Note: 271 response transactions emanating from other Blue Cross Plans (i.e. Blue Exchange) could contain other HIPAA compliant data. TOP

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Segment: Loop: Level: Usage: Notes:

MSG Subscriber Eligibility / Benefit Date

2110 C Detail Required Due to IBC/KHPE business practices, this information is provided.

Data Element Summary Ref Des Element Name MSG01

Element Note

Free-Form Message Text

Expect a Benefit Disclaimer

TOP

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Segment: Loop: Level: Usage: Notes:

PER Administrative Communications Contact

2100 D Detail Required Due to IBC/KHPE business practices, this information is provided.

Data Element Summary Ref Des Element Name PER03 Communication Number Qualifier PER04 Communication Number

Element Note Expect value: TE

(Telephone)

Expect Value: EDI/IS Phone Number

Note: 271 response transactions emanating from other Blue Cross Plans (i.e. Blue Exchange) could contain other HIPAA compliant data. TOP

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Segment: Loop: Level: Usage: Notes:

NM1

Subscriber Benefit Related Entity Contact Information

2120 C 2120 D Detail Required Due to IBC/KHPE business practices, this information is provided

Data Element Summary Ref Des Element Name NM101 Entity Identifier Code

Element Note Expect value(s): P3 (Primary Care Provider) 13 (Contracted Service Provider)

NM102

Entity Type Qualifier

Expect value(s): 2

NM103

Name Last or Organization Name Identification Code Qualifier Identification Code

Expect value: Physician or Facility Name

NM108 NM109

(Non Person Entity)

Expect value: SV Expect value: 10-digit network provider ID

Note: 271 response transactions emanating from other Blue Cross Plans (i.e. Blue Exchange) could contain other HIPAA compliant data. TOP

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Segment: Loop: Level: Usage: Notes:

NM1

Dependent Name

2100 D Detail Required Due to IBC/KHPE business practices, this information is provided

Data Element Summary Ref Des Element Name NM101 Entity Identifier Code

Element Note Expect value(s): 03 (Dependent)

NM102

Entity Type Qualifier

Expect value(s): 1

NM108

Dependent Identification Code Qualifier Identification Code

Expect Value: MI (Member Identification Qualifier)

NM109

(Person)

Expect Value: Member Identification Number

Note: 271 response transactions emanating from other Blue Cross Plans (i.e. Blue Exchange) could contain other HIPAA compliant data. TOP

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