Vx570 Transaction Guide Medicare Part A and B Eligibility

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1 Healthcare Point-of-Service Transactions VeriFone Vx570 Terminals Vx570 Transaction Guide Medicare Part A and B Eligibility January 29, 2013 Overview An Emdeon Medicare Part A and B eligibility transaction allows you to verify a beneficiary's eligibility status f a span of service dates. The Medicare transaction returns both Part A and Part B infmation. Part A and B providers can access this transaction f eligibility. Medicare Part A helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities. It also covers hospice care and some home health care. Medicare Part B helps cover your docts services, outpatient hospital care, some of the services of physical and occupational therapists, and some home healthcare. Medicare Part B helps pay f these covered services and supplies when they are medically necessary. The Medicare application is available 23 hours per day, seven days per week with limited downtime in the early mning f system updates. The Medicare HIPAA Eligibility Transaction System (HETS) will be loaded from the common wking files. HETS may be behind the Medicare common wking files by at least 24 hours. Claims to Medicare should be submitted using the HETS infmation returned from this transaction. Railroad beneficiaries are accessible through this transaction. Disclaimer: This transaction is not a guarantee of payment. Please read the disclaimer in the response f details. Date of Service Restrictions Up to 27 months in the past, including the current date. Up to four months in the future. Special Considerations Provider ID This payer permits use of a National Provider Identifier (NPI) only as the provider identifier. Search Requirements CMS has implemented me stringent search requirements f the Eligibility/Benefit transaction. The beneficiary s HIC number, first six bytes of the beneficiary s last name, and beneficiary s first initial must be entered exactly as it appears on the beneficiary s card. If the beneficiary has a suffix, it should be entered together with the last name. Because CMS matches only on the first six characters of the last name (excluding spaces and punctuation), the suffix will not be used in the match unless the last name is under six characters. F example, if the beneficiary s last name with suffix is Smith III, CMS will match on SmithI. If the beneficiary s last name with suffix is Johnson III, CMS will match on Johnso. CMS also requires the beneficiary s date of birth to match exactly what they have on file. Service Types CMS suppts the following service types: 1 (Medical Care), 14 (Renal Supplies in the Home), 15 (Alternate Method Dialysis), 30 (Health Benefit Plan Coverage), 33 (Chiropractic), 35 (Dental Care), 42 (Home Health Care), 45 (Hospice), 47 (Hospital), 86 (Emergency Services), 88 (Pharmacy), 98 (Professional [Physician] Visit Office), AG (Skilled Nursing Care), AL (Vision [Optometry]), MH (Mental Health) UC (Urgent Care). If a trading partner submits any of these service type codes, Emdeon will submit all of these codes to CMS. Any other valid service type is passed to CMS unaltered; CMS will respond as if a 30 were submitted. Customer Suppt Page 1 of 5

2 Current versus Histical Data The response returns only the spell data that has occurred within 60 days pri to the date of service. To receive histical spell infmation, you must enter a date of service within 60 days of the spell date, the date of service span must cover the spell date. Hospital Days Remaining Hospital Days remaining will be returned in an Eligibility/Benefit segment when your inquiry includes service type 47 (Hospital). If the inquiry is f the current date of service (the date on which the transaction was submitted), the number of hospital days remaining will be valid as of the current day. If your inquiry is f a pri date of service, if the date span extends into the past, the number of hospital days remaining will be valid as of the admission date shown in that segment. HMO Enrollment If the beneficiary has had HMO enrollment, the HMO infmation will appear in the response only if the beneficiary s HMO enrollment period is active if the requested date span covers the HMO end date. F example, if a beneficiary was enrolled in an HMO from January 1, 2009 through December 31, 2011, the HMO infmation will appear on the response only if your beginning ending dates of service fall on between January 1, 2009 and December 31, Incarceration If the patient is incarcerated during the date span submitted, then the person is ineligible. To Enter Letters 1. Press the number key on which the letter appears. 2. Press <ALPHA> once, twice, three times, until the letter appears. 3. If needed, press to delete the last character entered. 4. Special characters are on the * and # keys. Q, Z, and the decimal point (.) are on key 1. Other Usage Tips To display help infmation, press <F1>. If your terminal has been idle, you may be prompted to enter your user ID and passwd. You can assign shtcut keys (hot keys) to frequently-used payers. When you press a shtcut key from the idle prompt, your terminal will display the Transaction Type menu f the payer assigned to that key. To skip an optional prompt, press. F instructions on setting up a list of provider IDs, see your Verifone Vx570 User Guide. To display a list of entries f a prompt (e.g., provider IDs, gender types Service Types), press <F2>. Select your entry, then press. F me infmation, see your Verifone Vx570 User Guide. Request 1 2 WELCOME TO EMDEON SWIPE CARD OR PRESS ANY KEY MEDICAL ADDRESS VERIFY FINANCIAL SETUP LEARN MORE press any key. press <F2> f Medical (go to step 3) press an assigned shtcut key to start the payer program (go to step 4). 3 SELECT PAYER: select MEDICARE. SELECT SEARCH TYPE: Choose search: HIC#/Last 4 Name/DOB HIC#/Last Name/DOB. Go to step 5. HIC#/Last Name/First Name HIC#/Last Name/First Name. Go to step 15. HIC# last name date of birth searches: 5 Provider ID inquiring provider s National Provider Identifier (NPI). (Press <F2> f list.) 6 Prov Last/Org inquiring provider s Iast name ganization s name just to skip. 7 Prov First inquiring provider s first name just if the provider is an ganization. Customer Suppt Page 2 of 5

3 8 Medicare HIC # Medicare HIC number, exactly as on card. 9 Begin DOS begin date of service (mmddyy mmddyyyy) just f today s date. 24 Service Type service type just to skip. (Press <F2> f list.) You can enter up to seven service type codes. 10 End DOS end date of service (mmddyy mmddyyyy) just to repeat today s date. 11 Date of Birth patient s date of birth (mmddyyyy). 12 Last Name patient s last name. 13 Gender patient s gender just to skip. (Press <F2> f list.) 14 Service Type service type just to skip. (Press <F2> f list.) You can enter up to seven service type codes. HIC# last name first name searches: 15 Provider ID inquiring provider s National Provider Identifier (NPI). (Press <F2> f list.) 16 Prov Last/Org inquiring provider s Iast name ganization s name just to skip. 17 Prov First inquiring provider s first name just if the provider is an ganization. 18 Medicare HIC # Medicare HIC number, exactly as on card. 19 Begin Date 20 End Date begin date of service (mmddyy mmddyyyy) just f today s date. end date of service (mmddyy mmddyyyy) just to repeat today s date. 21 Last Name patient s last name. 22 First Name patient s first name. 23 Gender patient s gender just to skip. (Press <F2> f list.) Response The following section describes each section of infmation that your payer can return. Individual responses can vary in content. F a detailed dictionary of response data, see the POS v5 Standard Eligibility Response Dictionary. To reprint the last response, press <Scroll Line >. Input Infmation The infmation you entered in your request. Medicare Infmation Basic infmation about the transaction, such as: The Submit ID used f tracking The date and time the transaction was created (generated) by the payer/fiscal intermediary. Benefit Indicat: Y = Benefit infmation exists N = No benefit infmation exists P = Pending Q = QMB S = Spenddown Medicare Indicat: A = Patient has Medicare Part A coverage B = Patient has Medicare Part B coverage A&B = Patient has Medicare Parts A and B coverage NA = Unable to determine Medicare coverage Other Payer Indicat: Y = Patient has other payer coverage NA = Unable to determine other payer coverage Infmation Source Infmation about the payer, such as primary ID and name. Customer Suppt Page 3 of 5

4 Infmation Source Contact Payer contact infmation. Infmation Receiver Infmation about the requesting provider, such as primary ID and name. Infmation Receiver Provider Infmation Identifies the provider s role type in the eligibility/benefit being inquired about and it identifies the provider s Taxonomy Code specialty. Subscriber Infmation about the subscriber. Includes: The transaction audit (trace) numbers and igins The subscriber s primary ID Demographic infmation, such as name, date of birth, gender, and address are returned when the subscriber is the patient Birth sequence number assigned to each family member who is bn with the same birth date Indicates whether any identifying elements f the subscriber have changed from those submitted in the request Subscriber Additional ID Subscriber identification numbers other than the primary ID, such as the Medicare HIC number. The type of ID number is also described. This section can appear up to nine times. Subscriber Provider Infmation Identifies the subscriber s provider s role type, an additional identification qualifier, and provider ID Taxonomy Code. Subscriber Diagnosis Code The subscriber s principal diagnosis code, description, and code source and up to eight additional diagnosis codes, descriptions, and code sources. Subscriber Date A date range of dates relating to the subscriber s eligibility/benefits. The type of date and/ time is also described. If the type of date returned in this section is Eligibility, Eligibility Begin, Eligibility End, Admission, Service, it is implied that the date applies to all Eligibility/Benefit sections that follow unless there is a specific date in the Eligibility/Benefit section. Subscriber Military Personnel Infmation Infmation about the subscriber s military service, if applicable. This infmation is returned if the transaction is processed by the Department of Defense CHAMPUS/TRICARE. Includes: The status of the subscriber s military personnel infmation (e.g., Current, Latest, Oldest, etc.). The subscriber s general employment status (e.g., Active Military, Honably discharged, etc.). The subscriber s government service affiliation (e.g., Army, Air Fce, Coast Guard, etc.). A free-fm description that further identifies the subscriber s exact military unit. The subscriber s current most recent military rank. The beginning date date span of the subscriber s military service. Eligibility Benefit Details The eligibility and benefit sections give details about the patient s eligibility status and other types of benefits. There can be several eligibility and benefit sections. Each section header describes the eligibility status benefit type to which the section applies. Your response can include the following sections: Active Coverage Inactive Co-Insurance Deductible Benefit Description Limitations Other Additional Pay Note: A row of all dashes designates the beginning of another section of data of the same eligibility/benefit type as the preceding section. Infmation f each type of eligibility status benefit section can include: Coverage type Service types 1 Customer Suppt Page 4 of 5

5 Applicable dollar amount percentage Insurance type 2 Plan coverage infmation Benefit period Benefit amount Benefit percent Benefit quantity Authization certification required In-netwk indicat Product service ID Procedure Modifiers Primary diagnosis code pointer and up to three pointers cresponding to additional diagnosis codes in the der of imptance to the service Additional product service ID Benefit quantity Benefit frequency Benefit period Delivery frequency and time Additional ID types, ID numbers, and descriptions f the entity Up to 20 additional dates and/ times and types related to the benefit Messages relating to the benefit Additional infmation about the patient s injury The type of servicing facility Service limitations Benefit-related entity and entity contact infmation 1 see Service Types (HIPAA) 2 see Insurance Types (HIPAA) Err Messages Transaction-related err messages begin with CL, HT, RH, followed by a number and a line so of text. F a comprehensive description of all err messages, see the document Dictionary of Transaction Err Messages. Customer Suppt Page 5 of 5