Health Care Eligibility Benefit Inquiry and Response 270/271 ASC X12N 270/271 (005010X279A1)

Transcription

1 Health Care Eligibility Benefit Inquiry and Response 270/271 ASC X12N 270/271 (005010X279A1)

2 Table of Contents 1. Overview of Document General Information... 4 a. Patient Identification... 4 b. Dates of Service... 4 c. Transmission Size and Type Provider Identification BlueExchange Contact Information Data s Data s Proprietary work product of AmeriHealth 2 of 14

3 1. Overview of Document This guide is to be used as a supplement to the 270/271 Health Care Eligibility Benefit Inquiry version X279A1 Implementation Guide (hereinafter referred to as the 270/271). It should be used to process eligibility requests for AmeriHealth. In addition, transactions for members of other Blue Cross Plans can be submitted to AmeriHealth. This process, known as BlueExchange, has specific requirements and is described in a separate section within this document. This document is to be used to clarify the usage of specific data elements within the context of AmeriHealth s business practices. This Companion Document does not add, delete or change the name or usage of any data element that is specified in the HIPAA 270/271 Implementation Guide. Proprietary work product of AmeriHealth 3 of 14

4 2. General Information The 270-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 (e.g. AmeriHealth), and the Information Receiver is a Provider/Facility organization. a. Patient Identification The maximum sets of fields that an Information Source may require for look-up are defined in the HIPAA Implementation Guide. AmeriHealth prefers to receive the Member s, Member s Date of Birth, Member s First Name, and the Member s Last Name. However, AmeriHealth will perform the best search possible using the data received in the 270. Please review section and in the HIPAA 5010 Implementation Guide for more information. The AmeriHealth Patient consist of a 3-character alpha prefix, an 8-digit Universal Subscriber Id, and a 2-digit patient suffix. Ideally the entire should be supplied to ensure the Information Receiver quickly matches the request to the correct patient in AmeriHealth eligibility systems. A submitter should not use a member s Social Security Number; in fact AmeriHealth does not utilize the Social Security Number when it is included in the 2100C/D loop, REF02 data element and the REF01 is valued as SY. o If the 2100C/D loop, REF02 data element is supplied for any reason, it must not be all zeroes. Zeroes in this field will cause errors resulting in failed transactions. For AmeriHealth Mercy Members, the Member s must be submitted, inclusive of the YXM alpha-prefix. Member Name/DOB requests will not work for AmeriHealth Mercy Members. Additionally, for AmeriHealth Mercy member requests, must be submitted in the NM109 element of the 2100A Loop. b. Dates of Service For the 270 transaction, if a service date is not provided, AmeriHealth will use the current date to conduct the search. c. Transmission Size and Type Real time as defined in the HIPAA Implementation Guide is a real time transaction that contains an inquiry for no more than one patient. The Information Receiver, or their electronic intermediary, will send the 270 transaction to the Information Source through some means of telecommunications and will remain connected while the Information Source processes the transaction and returns a response. Proprietary work product of AmeriHealth 4 of 14

5 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, and IEA. 3. Provider Identification a. The provider is not used by AmeriHealth to process 270 requests for our members i. National Provider, Tax and AmeriHealth s corporate s will be accepted. b. The provider is required for BlueExchange 270 requests. See the BlueExchange section below. 4. BlueExchange The BlueExchange process is designed for inquiries about patients who are out of their local area and are often referred to as either Out-of-Area or Blue Card members. When a 270-eligibility inquiry is processed by AmeriHealth for one of these members, AmeriHealth can only identify them if the Patient, including alpha prefix, is provided (e.g. XYZ ). Without the alpha prefix, the patient will be treated as an AmeriHealth member only. When the correct patient is present, it enables the provider to request eligibility information from that member s Blue Cross plan. FEP, (Federal Employee Plan), member eligibility is also provided via BlueExchange. Federal Employees may be identified by their Patient, which begins with R and is followed by 8 numeric characters, (e.g. R ). The Blue Cross Blue Shield Association requires that trading partners provide the information receiver, (the provider), identification as follows: a. Enter the appropriate value or replace with a series of x if not available: Requesting Provider s NPI + Requesting Provider s Federal Tax + AmeriHealth Plan Code (Always 375) + Requesting Provider s 10-digit AmeriHealth Provider Number b. Further details are located in the 270 Data s section below. 5. Contact Information The 271 response transaction will contain contact information within the PER segment of the transaction. For further eligibility and benefit information members should contact Proprietary work product of AmeriHealth 5 of 14

6 Data s BHT Beginning of a Hierarchical Transaction Required AmeriHealth business practices require this information. Values of 01 and 36 in BHT02 are not valid for AmeriHealth. Data BHT02 Name Transaction Set Purpose Code Note Enter code value: 13 (Request) NM1 Information Source Name 2100A Required AmeriHealth business practices require this information. Data Name Note NM101 Entity Identifier Code Enter code value: PR (Payer) NM108 Identification Code Qualifier Enter code value: NI (National Association of Insurance Commissioners (NAIC) Identification) NM109 Identification Code Enter code value: Enter code value: (for AmeriHealth Mercy member requests ONLY) Proprietary work product of AmeriHealth 6 of 14

7 NM1 Information Receiver Name 2100 B Required AmeriHealth business practices require this information. Data NM101 Name Entity Identifier Code Note Facility Provider Request FA Professional Provider Requests 1P NM108 Identification Code Qualifier SV NM109 Identification Code Enter the appropriate value or replace with a series of x if not available: Requesting Provider s NPI + Requesting Provider s Federal Tax + AmeriHealth Plan Code (Always 375) + Requesting Provider s 10-digit AmeriHealth Provider Number The 32-character field should look like this: xxxxxxxxxxyyyyyyyyy375zzzzzzzzzz where x = NPI, y = Tax, z = 10-digit AmeriHealth Provider # Example #1: If the tax id is the only provider identifier you have: xxxxxxxxxx xxxxxxxxxx Example #2: If the Provider s NPI is the only provider identifier you have: xxxxxxxxx375xxxxxxxxxx Example #3: If the Provider s NPI and tax Id are the only provider identifiers you have: xxxxxxxxxx Example #4: If all provider identifiers are available: Proprietary work product of AmeriHealth 7 of 14

8 TRN Trace 2000 Situational AmeriHealth business practices require this information. Data Name Note TRN01 Trace Type Code 1 Please reference the HIPAA Implementation Guide for all other TRN segment data elements. Proprietary work product of AmeriHealth 8 of 14

9 NM1 Subscriber Name 2100 C Required AmeriHealth business practices require this information. Data Name Note NM108 Identification Code Enter code value: MI (Member Identification) Qualifier NM109 Identification Code Enter value: Universal Subscriber from the Patient s current card Examples: AmeriHealth PPO Q1B AmeriHealth Traditional Q1T AmeriHealth HMO/POS Q1C (Do not include the 1 character letter that may be at the end of the number) AmeriHealth Mercy (AMHP) YXM Out-of-Area XYZ123 through XYZ (6 17 characters) FEP R Proprietary work product of AmeriHealth 9 of 14

10 EQ Service Type Code 2110C/D Required AmeriHealth business practices can handle any service type value in use by the HIPAA 270. However, the list below represents those service types where AmeriHealth is able to provide specific benefit limitations and details. All other service types will be responded to with general benefit information. Data Name Note EQ01 Service Type Code Enter code value: The service types where AmeriHealth is able to provide specific benefit limitations and details are: Service Type Requested 1 Medical Care 88 Pharmacy (Active/Inactive Only) 2 Surgical 98 Professional (Physician) Visit - Office 4 Diagnostic X-Ray 99 Professional (Physician) Visit - Inpatient 5 Diagnostic Lab A0 Professional (Physician) Visit - Outpatient 6 Radiation Therapy A3 Professional (Physician) Visit - Home 7 Anesthesia AD Occupational Therapy 8 Surgical Assistance AF Speech Therapy 12 Durable Medical Equipment Purchase AG Skilled Nursing Care 13 Ambulatory Service Center Facility AI Substance Abuse 18 Durable Medical Equipment Rental AL Vision (Optometry) 20 Second Surgical Opinion BG Cardiac Rehabilitation 30 Health Benefit Plan Coverage (General) BH Pediatric 33 Chiropractic BT Gynecological 35 Dental Care (Active/Inactive Only) BU Obstetrical 40 Oral Surgery BV Obstetrical/Gynecological 42 Home Health Care BY Physician Visit Office: Sick 45 Hospice BZ Physician Visit Office: Well 47 Hospital CE MH Provider Inpatient 48 Hospital - Inpatient CF MH Provider Outpatient 50 Hospital - Outpatient CG MH Provider Facility Inpatient 51 Hospital - Emergency Accident CH MH Provider Facility Outpatient 52 Hospital - Emergency Medical CI Substance Abuse Facility Inpatient 53 Hospital - Ambulatory Surgical CJ Substance Abuse Facility Outpatient 60 General Benefits (Active/Inactive Only) CK Screening X-ray 61 In-vitro Fertilization CL Screening Laboratory 62 MRI/CAT Scan CM Mammogram, HR Patient 65 Newborn Care CN Mammogram, LR Patient 68 Well Baby Care CO Flu Vaccination 69 Maternity DM Durable Medical Equipment Proprietary work product of AmeriHealth 10 of 14

11 Service Type Requested 73 Diagnostic Medical MH Mental Health 76 Dialysis PT Physical Therapy 78 Chemotherapy UC Urgent Care 80 Immunizations 81 Routine Physical 82 Family Planning 83 Infertility 84 Abortion 86 Emergency Services EQ04 Insurance Type Code NOT USED under HIPAA 5010A1 (formerly, under HIPPA 4010, an MC was placed in this element to indicate that the request was for Medicaid eligibility.) Proprietary work product of AmeriHealth 11 of 14

12 Data s REF Reference Identification 2100C/D Situational AmeriHealth business practices require this information when the Patient was corrected within the response. Data REF01 Name Reference Identification Qualifier Note Expect value: Q4 (Prior Identifier Number) NOTE: This code is to be used when a corrected or new identification number is returned in 2100C/D, the NM1 segment, the NM109 data element REF02 Reference Identification Expect value: Originally submitted Patient INS Insured Benefit 2100C/D Required AmeriHealth business practices require this information when identifying Patient information was corrected within the response. Data INS01 Name Yes/No Condition or Response Code Note See HIPAA Implementation Guide Proprietary work product of AmeriHealth 12 of 14

13 Data INS02 Name Individual Relationship Code Note See HIPAA Implementation Guide INS03 INS04 Maintenance Type Code Maintenance Reason Code Expect value: 001 Expect value: 25 EB Subscriber/Dependent Eligibility or Benefit Information 2110C/D Situational AmeriHealth will populate this segment with the elements described below when a member is found to have greater than one active policy. Data Name Note EB01 Eligibility/Benefit Information Code Expect Value R for Other Payor EB03 Service Type Code Expect Value 30 EB04 Insurance Type Code Expect Value GP EB05 Plan Coverage Description Expect the Other Payor s Name NM1 Subscriber Benefit Related Entity Contact Information 2120C/D Situational AmeriHealth will populate this segment with the elements described below when a member is found to have greater than one active policy. Proprietary work product of AmeriHealth 13 of 14

14 Data Name Note NM103 Last Name Expect value: Other Insured Last Name Set NM101 = IL; NM108 = MI NM104 First Name Expect value: Other Insured First Name Set NM101 = IL: NM108 = MI NM105 Middle Initial Expect value: Other Insured Middle Initial Set NM101 = IL: NM108 = MI NM109 Identification Number Expected value: Other Insured Identification Number Set NM101 = IL; NM108 = MI NM1 Subscriber Benefit Related Entity Contact Information 2120C/D Situational AmeriHealth business practices require this information when the identified Patient is an HMO member. Data Name Note NM101 Entity Identifier Code Expect value(s): P3 (Primary Care Provider) 13 (Contracted Service Provider) Note: The following capitated servicing providers may be returned in the response and can be identified by 13 in NM101 Lab Radiology Physical Therapy Podiatry Proprietary work product of AmeriHealth 14 of 14