270/271 Healthcare Eligibility Benefit Inquiry and Response Transaction Standard Companion Guide

Transcription

1 270/271 Healthcare Eligibility Benefit Inquiry and Response Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version January 2013

2 Disclosure Statement This Companion Guide is issued in an effort to provide Trading Partners of SelectHealth with the most up-todate information related to Standard Transactions. Any and all information in this guide is subject to change at any time without notice. Every effort has been made to assure the information in this guide conforms to current requirements of the law. Each Trading Partner has the ultimate responsibility to follow federal and state laws. Each time you test or submit a Standard Transaction, we recommend that you refer to the most recently posted Companion Guide to ensure you are using the most current information available. Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with SelectHealth. Transmissions based on this companion guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. 1 INTRODUCTION This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each additional segment beyond what is listed in the IGs and and may perform the following: 1. Limit the repeat of loops or segments 2. Limit the length of a simple data element 3. Specify a subset of the IGs internal code listings 4. Clarify the use of loops, segments, composite, and simple data elements 5. Request any other information tied directly to a loop, segment, composite, or simple data element pertinent to trading electronically with SelectHealth In addition to the row for each segment, one or more rows are used to describe how SelectHealth uses composite and simple data elements as well as for any other information. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. Scope This guide is intended to provide supplemental information regarding electronic eligibility benefit inquiries (270) and electronic eligibility benefit responses (271). It follows the requirements in the ASC X12N 270/271 Technical Report 3 for version X279A1 and is used to more accurately define the response that you will receive. Please refer to the Technical Report for information on definitions, loops, segments, elements, data structure, etc. Overview This document explains initial transaction set up, testing procedures, and information on troubleshooting possible errors received on a 271 transaction. Page # Loop ID Reference Name Codes Length Notes/Comments C NM1 Subscriber Name This type of row always exists to indicate that a new segment has begun. It is always shaded at 10% and notes or comment about the segment itself goes in this cell C NM109 Subscriber Primary Identifier 15 This type of row exists to limit the length of the specified data element C REF Subscriber Additional Identification C REF01 Reference Identification Qualifier Plan Network Identification Number C EB Subscriber Eligibility or Benefit Information C EB13-1 Product/Service ID Qualifier 18, 49, 6P, HJ, N6 N6 AD This type of row exists to show the only codes transmitted by SelectHealth. This type of row exists when a note for a particular code value is required. For example, this note may say that value N6 is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it This row illustrates how to indicate a component data element in the Reference column and also how to specify that only one code value is applicable. 2

3 References Information on the ASC X12N 270/271 Technical Report 3 for version X279A1 can be found at the Washington Publishing Company website at wpc-edi.com. 2 GETTING STARTED Provider Process Flowchart Clearinghouse Trading Partner Registration To initiate participation in the eligibility benefit inquiry and response, call the SelectHealth EDI department. A Utah Health Information Network (UHIN) trading partner number and name will be required to establish the transaction in the SelectHealth system. Once set up is complete, 270 s may be submitted via UHIN using the SelectHealth production trading partner number HT Certification and Testing Overview SelectHealth does not require test transactions before trading partners can be set up in the production environment. A test environment is available for trading partners wishing to test before submitting production data. 3 TESTING WITH THE PAYER Trading partners wishing to submit 270s to the test environment will need to contact UHIN and the SelectHealth EDI department in order to be set up in the test environment. Once set up is complete, 270 s may be submitted via UHIN using the SelectHealth production trading partner number HT CONNECTIVITY WITH THE PAYER/COMMUNICATIONS Process Flows Trading partners send 270s to UHIN, and UHIN routes them to SelectHealth. A clearinghouse can also be used to submit the 270 to UHIN. Retransmission Procedure At this time, SelectHealth is unable to retransmit 271s, 999s, or TA1s. If a response is lost or not received, the 270 will need to be resubmitted. Communication Protocol Specifications SelectHealth requires all external trading partners to submit electronic transactions through UHIN. The UHIN Connectivity Companion Guide can be found on the UHIN website at UHIN.org. Trading partners must be a UHIN member to access the guide and a log in is required. Passwords When trading partners register with UHIN, they will receive a username and password that can be used to submit the 270 or any other electronic transaction. UHIN SelectHealth 5 INFORMATION EDI Customer Service and Technical Assistance For specific questions about Healthcare Eligibility Benefit Inquiry and Response transactions, please call the SelectHealth EDI department at (Salt Lake area) or weekdays, from 8:00 a.m. to 5:00 p.m. or send a fax to Provider Service Number If you have general questions not related to the EDI process, call SelectHealth Member Services at (Salt Lake area) or weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays from 9:00 a.m. to 2:00 p.m. UHIN Member Services can be reached at Applicable Websites/ SelectHealth EDI department address: HPEDI@imail.org SelectHealth EDI website: intermountainphysician.org/ selecthealth/edi SelectHealth website: selecthealth.org UHIN: uhin.org 6 CONTROL SEGMENTS/ENVELOPES ISA-IEA SelectHealth does not require authorization codes to be sent in the 270 transaction. A UHIN trading partner number, beginning with HT, must be submitted in ISA06. GS-GE SelectHealth will accept multiple GS-GE sets in a single transaction. 3

4 ST-SE SelectHealth will accept multiple ST-SE sets in a single transaction. Each ST-SE will be separated within the SelectHealth system and will be returned to the trading partner as a single transaction. For example, when one 270 is sent with five ST-SE sets, five 271 transactions will be returned. 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS System Availability The SelectHealth 270/271 transaction is available 24 hours a day, seven days a week. Any planned downtimes will be communicated to UHIN and trading partners in advance. If there is any difficulty receiving a response from SelectHealth, please call the EDI department. SelectHealth will communicate any scheduled system maintenance to UHIN and trading partners in advance. Batch And Real Time A 270 inquiry may be sent using batch or real time. SelectHealth will respond to a 270 inquiry in batch mode within 24 hours. A real-time transaction will receive a response in 20 seconds or less and will only include one patient. Additional patients require more processing time and will be processed as a batch. the use of a table. The tables contain a row for each for each additional segment beyond what is listed in the IGs and and may perform the following: 1. Limit the repeat of loops or segments 2. Limit the length of a simple data element 3. Specify a subset of the IGs internal code listings 4. Clarify the use of loops, segments, composite, and simple data elements 5. Request any other information tied directly to a loop, segment, composite, or simple data element pertinent to trading electronically with SelectHealth In addition to the row for each segment, one or more rows are used to describe how SelectHealth uses composite and simple data elements as well as for any other information. The table on the following page specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. 8 ACKNOWLEDGEMENTS AND/OR REPORTS A 999 and TA1 will be returned for validation errors on the 270 inquiry. A 999 will not be returned if the 270 passes validation due to the fast batch process SelectHealth uses on batch transactions. If there are problems with any inquiry or data element, the entire file will be rejected. 9 TRADING PARTNER AGREEMENTS Trading Partners An EDI trading partner is defined as any SelectHealth customer (e.g., provider, billing service, software vendor, employer, financial institution) that transmits to or receives electronic data from SelectHealth. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. Trading Partner agreements will be handled through UHIN. 10 TRANSACTION SPECIFIC INFORMATION This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with 4

5 Page # Loop ID Reference Name Codes Notes/Comments C EQ01 Subscriber Eligibility or Benefit Inquiry D EQ01 Dependent Eligibility or Benefit Inquiry 1, 2, 4, 5, 6, 7, 8, 11, 12, 13, 18, 20, 23, 24, 25, 26, 27, 28, 30, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 44, 46, 47, 48, 49, 50, 51, 52, 53, 54, 56, 59, 62, 65, 66, 68, 68, 69, 73, 75, 76, 77, 78, 80, 81, 82, 86, 88, 93, 94, 97, 98, 99, A0, A3, A4, A6, A7, A8, AD, AE, AF, AG, AI, AL, AM, AN, AO, B1, BG, BH, BT, BU, BV, CC, CD, CF, CH, CJ, CP, DG, DM, IC, MH, NI, PT, RT, UC 1, 2, 4, 5, 6, 7, 8, 11, 12, 13, 18, 20, 23, 24, 25, 26, 27, 28, 30, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 44, 46, 47, 48, 49, 50, 51, 52, 53, 54, 56, 59, 62, 65, 66, 68, 68, 69, 73, 75, 76, 77, 78, 80, 81, 82, 86, 88, 93, 94, 97, 98, 99, A0, A3, A4, A6, A7, A8, AD, AE, AF, AG, AI, AL, AM, AN, AO, B1, BG, BH, BT, BU, BV, CC, CD, CF, CH, CJ, CP, DG, DM, IC, MH, NI, PT, RT, UC SelectHealth is able to provide a specific response to these codes. All other valid codes will receive Health Benefit Plan Coverage (30) response. SelectHealth is able to provide a specific response to these codes. All other valid codes will receive Health Benefit Plan Coverage (30) response C Subscriber Level SelectHealth offers an advanced search option that will attempt to identify the member whether or not he or she was submitted as a subscriber or a dependent. To provide the most accurate information possible, SelectHealth will return the member in the correct loop according to the member s status. For example, if the member is submitted as a subscriber but the member search discovers that he or she is actually a dependent, that information will be returned in the dependent loop. The correct subscriber name and subscriber ID will be returned in the subscriber loop C REF Subscriber Additional Identification C AAA Subscriber Request Validation C AAA03 Reject Reason Code Transaction specific information Required Application Data Missing Unable to Respond at Current Time Date of Service Not Within Allowable Inquiry Period Invalid/Missing Subscriber Information 15, 42, 58, 62, 72, 73, 75 This segment is used to communicate the original subscriber ID submitted in the 270 when the one being returned on the 271 is different. 15 To complete a patient search, SelectHealth requires at least three of the four following member identifiers be submitted: subscriber ID, last name, first name, date of birth. If these are not received, an AAA03 = 15 will be returned. SelectHealth also requires that a service type code (EQ01) be submitted for every patient inquiry. If there is no dependent loop and an EQ segment is not present in the subscriber loop, an AAA03 = 15 will be returned. 42 If the SelectHealth system is not available, an AAA03 = 42 will be returned. 62 SelectHealth does not allow inquiries more than 12 months in the past. Inquiry date spans requests cannot exceed 30 days. If either condition occurs, an AAA03 = , 73, 75, 76, 58 Used when a member not found or multiple match has occurred during the member search process. A patient not found response may be the result of several factors. If only three identifiable qualifiers of information are sent and one is spelled differently in the SelectHealth system, a patient not found response may be returned. Verify that the submitted information is accurate, and if possible, that the member has a SelectHealth ID Card. If the patient is a newborn and a patient not found response is received, sending only the last name, subscriber ID, and date of birth may help find the member. (continued)

6 Page # Loop ID Reference Name Codes Notes/Comments Invalid/Missing 72, 73, 75, 76, 58 (continued) Subscriber A patient not found response will contain AAA information segments with AAA03 value of 75 (Subscriber/Insured Not Found). An exception to this occurs when the subscriber ID, date of birth, first name, and last name are all sent in the request. In this case, a combination of 58, 72, and 73 (Invalid Date of Birth, Invalid Subscriber ID, and Invalid Subscriber Name) will be included with the response. A multiple members found response may be the result of sending insufficient qualifier information to search for a member. If you receive an AAA segment resulting in multiple matches, try obtaining more information from the member to use in the search. If the member has dual coverage through SelectHealth and a specific subscriber ID is not sent, call Member Services to obtain eligibility and benefit information. A multiple members found response will contain AAA segments with AAA03 value of 76 (Duplicate Subscriber/ Insured Found) C EB Subscriber Eligibility and Benefit Information C EB03 Service Type Code The repetition separator can be utilized by trading partners on inbound 270 transactions. To be compliant with the 5010 TR3, SelectHealth uses the repetition separator on the outbound 271 for eligibility and benefits that are similar. A caret (^) will be used as the separator. Medical Care 1 The following service-type codes will be returned with a 1 Medical Care response: 48 Hospital Inpatient 50 Hospital Outpatient 52 Hospital Emergency Medical 98 Hospital Emergency Medical 1 Medical Care Health Benefit Plan Coverage 30 The following service type codes will be returned with a 30 Health Benefit Plan Coverage response: Eligibility and benefit lines: DM Durable Medical Equipment 33 Chiropractic 48 Hospital Inpatient 50 Hospital Outpatient 52 Hospital Emergency Medical 69 Maternity 86 Emergency Services 88 Pharmacy 98 Professional (Physician) Visit Office AL Vision UC Urgent Care 30 Health Benefit Plan Coverage 1 Medical Care 47 Hospital Benefits 35 Dental Care MH Mental Health Only dental eligibility will be returned on a 30 Health Benefit Plan Coverage response. To receive dental benefits, a specific dental code or the 35 DentalCare inquiry must be sent in a 270 request. Also, on a 30 Health Benefit Plan Coverage response, only the eligibility line of MH Mental Health will be returned. If specific mental health benefits are needed, a MH Mental Health request must be sent in a 270 inquiry. The MH response will return the following information: benefits, deductible, out-of-pocket, and outpatient visit limits and accumulators.

7 Page # Loop ID Reference Name Codes Notes/Comments Dental Care 35 The following service type codes will be returned with a 35 Dental Care response: Eligibility and benefit lines: 23 Diagnostic Dental 24 Periodontics 25 Restorative 26 Endodontics 27 Maxillofacial Prosthetics 28 Adjunctive Dental Services 36 Dental Crowns 38 Orthodontics 39 Prosthodontics 41 Routine (Preventive) Dental 35 Dental Care Dental Accident 37 Due to the complexity of dental accidents, only an eligibility line will be returned when a 37 Dental Accident request is submitted on a 270 inquiry. For specific benefit information, call Member Services. Oral Surgery 40 Due to the complexity of oral surgery, only an eligibility line will be returned when a 40 Oral Surgery request is submitted on a 270 inquiry. For specific benefit information, call Member Services. Hospital 47 The following service type codes will be returned with a 47 Hospital response: 48 Hospital Inpatient 50 Hospital Outpatient 52 Hospital Emergency Medical 47 Hospital Surgical Benefits - Professional CC The following service type codes will be returned with a CC Surgical Benefits Professional response: 48 Hospital Inpatient 50 Hospital Outpatient 53 Hospital Ambulatory Surgery CC Surgical Benefits Professional D Dependent Level SelectHealth offers an advanced search option that will attempt to identify the member whether or not he or she was submitted as a subscriber or a dependent. To provide the most accurate information possible, SelectHealth will return the member in the correct loop according to the member s status. For example, if the member is submitted as a subscriber but the member search discovers that he or she is actually a dependent, that information will be returned in the dependent loop. The correct subscriber name and subscriber ID will be returned in the subscriber loop D REF Dependent Additional Identification D AAA Dependent Request Validation D AAA03 Reject Reason Code Required Application Data Missing 15, 42, 58, 62, 64, 65, 67, 76 This segment is used to communicate the original subscriber ID submitted in the 270 when the one being returned on the 271 is different. 15 SelectHealth requires at least three of the four following member identifiers be submitted in order to complete a patient search: subscriber ID, last name, first name, or date of birth. If these are not received, an AAA03 = 15 will be returned. SelectHealth also requires that a service type code (EQ01) be submitted for every patient inquiry. If there is no dependent loop and an EQ segment is not present in the subscriber loop, an AAA03 = 15 will be returned.

8 Page # Loop ID Reference Name Codes Notes/Comments Unable to Respond at Current Time Date of Service Not Within Allowable Inquiry Period Invalid/Missing Subscriber Information D EB Subscriber Eligibility and Benefit Information D EB03 Service Type Code 42 If the SelectHealth system is not available, an AAA03 = 42 will be returned. 62 SelectHealth does not allow inquiries more than 12 months in the past. Inquiry date span requests cannot exceed 30 days. If either condition occurs, an AAA03 = 62 will be returned 64, 65, 67, 68, 58 When a member is not found or multiple matches have been found during the member search process, a patient not found response may be returned. If only three identifiable qualifiers of information are sent and one is spelled differently in the SelectHealth system, a patient not found response may be returned. Verify that the submitted information is accurate, and if possible, that the member has a SelectHealth ID Card. If the patient is a newborn and a patient not found response is received, sending only the last name, subscriber ID, and date of birth may help find the member. A patient not found response will contain AAA segments with AAA03 value of 67 (Patient Not Found). An exception to this occurs when the subscriber ID, date of birth, first name, and last name are all sent in the request. In this case, a combination of 58, 64, and 65 (Invalid Date of Birth, Invalid Patient ID, Invalid Patient Name) will be returned. A multiple members found response may be the result of sending insufficient qualifier information to search for a member. If you receive an AAA segment resulting in multiple matches, try obtaining more information from the member to use in the search. If the member has dual coverage through SelectHealth and a specific subscriber ID is not sent, call Member Services for eligibility and benefit information. A multiple members found response will contain AAA segments with AAA03 value of 68 (Duplicate Patient Found). The repetition separator can be utilized by trading partners on inbound 270 transactions. To be compliant with the 5010 TR3, SelectHealth uses the repetition separator on the outbound 271 for eligibility and benefits that are similar. A caret (^) will be used as the separator. Medical Care 1 The following service type codes will be returned with a 1 Medical Care response: 48 Hospital Inpatient 50 Hospital Outpatient 52 Hospital Emergency Medical 98 Professional Office Visits 1 Medical Care Health Benefit Plan Coverage 30 The following service type codes will be returned with a 30 Health Benefit Plan Coverage response: Eligibility and benefit lines: DM Durable Medical Equipment 33 Chiropractic 48 Hospital - Inpatient 50 Hospital - Outpatient 52 Hospital - Emergency Medical 69 Maternity 86 Emergency Services 88 Pharmacy 98 Professional (Physician) Visit - Office AL Vision UC Urgent Care (continued)

9 Page # Loop ID Reference Name Codes Notes/Comments Health Benefit Plan Coverage 30 (continued) 30 Health Benefit Plan Coverage 1 Medical Care 47 Hospital Benefits 35 Dental Care MH Mental Health Only dental eligibility will be returned on a 30 Health Benefit Plan Coverage response. To receive dental benefits, a specific dental code or the 35 Dental Care inquiry must be sent in a 270 request. Also, on a 30 Health Benefit Plan Coverage response, only the eligibility line of MH Mental Health will be returned. If specific mental health benefits are needed, a MH Mental Health request must be sent in a 270 inquiry. The MH response will return the following information: benefits, deductible, out-of-pocket, and outpatient visit limits and accumulators. Dental Care 35 The following service type codes will be returned with a 35 Dental Care response: Eligibility and benefit lines: 23 Diagnostic Dental 24 Periodontics 25 Restorative 26 Endodontics 27 Maxillofacial Prosthetics 28 Adjunctive Dental Services 36 Dental Crowns 38 Orthodontics 39 Prosthodontics 41 Routine (Preventive) Dental 35 Dental Care Dental Accident 37 Due to the complexity of dental accidents, only an eligibility line will be returned when a 37 Dental Accident request is submitted on a 270 inquiry. For specific benefit information, call Member Services. Oral Surgery 40 Due to the complexity of oral surgery, only an eligibility line will be returned when a 40 Oral Surgery request is submitted on a 270 inquiry. For specific benefit information, call Member Services. Hospital 47 The following service type codes will be returned with a 47 Hospital response: 48 Hospital Inpatient 50 Hospital Outpatient 52 Hospital Emergency Medical 47 Hospital Surgical Benefits - Professional CC The following service type codes will be returned with a CC Surgical Benefits Professional response: 48 Hospital Inpatient 50 Hospital Outpatient 53 Hospital Ambulatory Surgery CC Surgical Benefits - Professional

10 APPENDICES 1. Implementation Checklist Contact UHIN and complete setup in the UHIN system. Contact SelectHealth and complete setup in the SelectHealth system. Test using the production mirror UHIN environment, if desired. Instructions on are available through UHIN. 2. Business Scenarios None at this time. 3. Transmission Examples None at this time. 4. Frequently Asked Question Question: Does SelectHealth accept batch, real time, or both? Answer: SelectHealth provides a fast batch and real-time option. Depending on the complexity of the inquiry and number of inquiries within a transaction, a batch will be processed close to real-time speeds. 5. Change Summary Date of Change Change 01/01/2013 Updated Companion Guide to include changes for the CORE Operating Rules. Flow and format updated in compliance with Rule SelectHealth. All rights reserved /13