Healthcare Eligibility Benefit Inquiry and Response

Healthcare Eligibility Benefit Inquiry and Response

Healthcare
Eligibility
Benefit Inquiry
and Response
270/271 5010 Companion Guide
Table of Contents
Purpose.............................................................................................................................................1
Contact Information.......................................................................................................................1
Preparation and Testing Requirements.........................................................................................1
System Availability...........................................................................................................................2
Batch and Real Time.......................................................................................................................2
SelectHealth Eligibility Response (271)........................................................................................2
Member Search................................................................................................................................2
Patient Not Found Response.........................................................................................................3
Multiple Members Found Response..............................................................................................3
Subscriber and Dependent Loops.................................................................................................3
Eligibility and Benefit Information...............................................................................................4
In-Plan Network Indicator.............................................................................................................4
Service Type Codes.....................................................................................................................4
EQ Codes.....................................................................................................................................4
30 – Health Benefit Plan Coverage...........................................................................................6
Dental Requests...........................................................................................................................7
35 – Dental Care..........................................................................................................................7
37 – Dental Accident..................................................................................................................7
40 – Oral Surgery........................................................................................................................7
54 – Long-Term Care.................................................................................................................8
1 – Medical Care..........................................................................................................................8
47 – Hospital................................................................................................................................8
CC – Surgical Benefits – Professional......................................................................................8
Mental Health Requests..............................................................................................................9
Third-Party Administrators........................................................................................................9
Eligibility and Benefit Dates......................................................................................................9
Limits and Accumulators.........................................................................................................10
Pre-existing Condition (PEC)..................................................................................................10
Coordination of Benefits (COB).............................................................................................10
Purpose
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 005010X279A1
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.
For more information on the Technical Report, visit the Washington Publishing Company
at wpc-edi.com.
Contact Information
For specific questions about Healthcare Eligiblity Benefit Inquiry and Response
transactions, please call the SelectHealth EDI department at 801-442-5442 (Salt Lake area)
weekdays, from 8:00 a.m. to 5:00 p.m. or fax to 801-442-0372.
If you have additional questions, call SelectHealth Member Services at 801-442-5038
(Salt Lake area) or 800-538-5038 weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays
from 9:00 a.m. to 2:00 p.m.
Preparation and Testing Requirements
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. The
SelectHealth trading partner number can then be obtained from the EDI department.
Once setup is complete, a member of the team will initiate contact and verify that
transactions can be sent.
1
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.
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 60 seconds or less and will only include one patient. Additional patients require more
processing time and will be processed as a batch.
SelectHealth Eligibility Response (271)
The information below provides more detail on how SelectHealth will utilize the 271 to
respond to eligibility requests (270). It may also help you troubleshoot issues when an
error response is returned.
Member Search
To identify a member, inquiries must include at least three of the following qualifiers:
• Subscriber ID
• Last name
• First name
• Date of birth
If at least three of these qualifiers are not present in the 270, an “AAA” response will be
returned. AAA03 will state “15 – Required Application Data Missing.”
If the Social Security number is provided on the 270, SelectHealth may use it to locate
the member.
2
“Patient Not Found” Response
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.
A “patient not found” response will contain AAA segments with AAA03 values of 75
(Subscriber/Insured Not Found) or 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, 72 and 73 (Invalid Date of Birth, Invalid Subscriber ID,
and Invalid Subscriber Name) or 58, 64, and 65 (Invalid Date of Birth, Invalid Patient ID,
Invalid Patient Name) will be returned.
“Multiple Members Found” Response
A “multiple members found” response may be the result of sending insufficient qualifier
information to search for a member. If you recieve 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 values of
76 (Duplicate Subscriber/Insured Found) or 68 (Duplicate Patient Found).
Subscriber and Dependent Loops
SelectHealth offers an advanced search option that will attempt to identify the member
regardless of whether 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,
the information will be returned in the dependent loop. The correct subscriber name and
subscriber ID will be returned in the subscriber loop.
If the subscriber ID has changed from the one submitted on the 270, the correct ID will
be returned in the NM109 element of the subscriber loop. The original ID will also be
returned in the REF02 element in the patient loop using the REF01 = Q4 qualifier.
3
Eligibility and Benefit Information
In-Plan Network Indicator
The In-Plan Network Indicator (EB12) is used to communicate whether the eligibility
or benefit is considered participating or nonparticipating. SelectHealth is only
returning participating benefits and eligibility at this time. Any noncovered response
is for participating only and does not preclude the member from having covered
nonparticipating benefits and eligibility. Please call Member Services for nonparticipating
benefits and eligibility.
Service Type Codes
If available, each service type code will be returned with eligibility information in addition
to copay, coinsurance, deductible, and out-of-pocket amounts for individual and family
limits and accumulators. Visit limits will also be returned when available.
EQ Codes
The 5010 guide requires each inquiry to provide a service type code (EQ code).
Transactions that do not provide this will receive an AAA segment with an AAA03 = 15.
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“^” will be used as the separator.
SelectHealth will provide a specific participating benefit response to the following EQ codes:
1
2
4
5
7
11
12
13
18
23
24
25
26
27
28
30
33
Medical Care
Surgical
Diagnostic X-Ray (Minor diagnostic benefit)
Diagnostic Lab (Minor diagnostic benefit)
Anesthesia
Used Durable Medical Equipment
Durable Medical Equipment Purchase
Ambulatory Service Center Facility
Durable Medical Equipment Rental
Diagnostic Dental
Periodontics
Restorative
Endodontics
Maxillofacial Prosthetics
Adjunctive Dental Services
Health Benefit Plan Coverage
Chiropractic
4
34
35
36
37
38
39
40
41
42
44
47
48
49
50
52
53
54
56
59
62
66
68
69
73
75
77
80
81
82
86
88
94
97
98
A4
A6
A8
AD
AF
AI
AL
Chiropractic Office Visits
Dental Care
Dental Crowns
Dental Accidents
Orthodontics
Prosthodontics
Oral Surgery
Routine (preventive) Dental
Homecare
Home Health Visits
Hospital
Hospital Inpatient
Hopsital Room and Board
Hospital Outpatient
Hospital Emergency Medical (ER Benefits)
Hospital – Ambulatory Surgical
Long-Term Care
Medically Related Transportation
Ambulance
MRI/CAT Scan
Pathology
Well Baby Care
Maternity
Diagnostic Medical
Prosthetic Device
Otological Exam
Immunizations
Routine Physical
Family Planning
Emergency Services – Professional
Pharmacy
Podiatry Office Visits
Anesthesiologist
Professional (Physician) Visit – Office
Psychiatric
Psychotherapy
Psychatric Outpatient
Occupational Therapy
Speech Therapy
Substance Abuse
Vision
5
AM
AN
AO
B1
BT
BU
BV
CC
CD
CF
CH
CJ
CP
DG
DM
IC
MH
NI
PT
RT
UC
Frames
Vision Routine Exam
Lenses
Burn Care
Gynecological
Obstetrical
Obstetrical/Gynecological
Surgical Benefits – Professional
Surgical Benefits – Facility
Mental Health Provider – Outpatient
Mental Health Facility – Outpatient
Substance Abuse Facility – Outpatient
Eyewear and Eyewear Accessories
Dermatology
Durable Medical Equipment
Intensive Care
Mental Health
Neonatal Intensive Care
Physical Therapy
Residential Psychiatric Treatment
Urgent Care
30 – Health Benefit Plan Coverage
The following service type codes will be returned with a “30 – Health Benefit Plan
Coverage” response:
Eligibility and benefit lines:
DM
33
48
50
52
69
86
88
98
AL
UC
Durable Medical Equipment
Chiropractic
Hospital – Inpatient
Hospital – Outpatient
Hospital – Emergency Medical
Maternity
Emergency Services
Pharmacy
Professional (Physician) Visit – Office
Vision
Urgent Care
6
Eligibility line only:
30
1
47
35
MH
Health Benefit Plan Coverage
Medical Care
Hospital Benefits
Dental Care
Mental Health
Dental Requests
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.
35 – Dental Care
The following service type codes will be returned with a “35 – Dental Care” response:
Eligibility and benefit lines:
23
24
25
26
27
28
35
36
38
39
41
Diagnostic Dental
Periodontics
Restorative
Endodontics
Maxillofacial Prosthetics
Adjunctive Dental Services
Dental Care
Dental Crowns
Orthodontics
Prosthodontics
Routine (preventive) Dental
37 – Dental Accident
Due to the complexity of dental accidents, only a medical eligibility line will be
returned when a “37 – Dental Accident” request is submitted on a 270 inquiry. For
specific benefit information, please call Member Services.
40 – Oral Surgery
Due to the complexity of oral surgery, only a medical eligibility line will be
returned when a “40 – Oral Surgery” request is submitted on a 270 inquiry. For
specific benefit information, please call Member Services.
7
54 – Long-Term Care
Long-term care will contain benefits for long-term acute care only. Please call Member
Services for inquiries regarding skilled nursing or hospice.
1 – Medical Care
The following service type codes will be returned with a “1 – Medical Care” response:
Eligibility and benefits:
48
50
52
98
Hospital Inpatient
Hospital Outpatient
Hospital Emergency Medical
Professional Office Visits
Eligibility line only:
1
Medical Care
47 – Hospital
The following service type codes will be returned with a “47-Hospital” response:
Eligibility and benefits:
48
50
52
Hospital Inpatient
Hospital Outpatient
Hospital Emergency Medical
Eligibility line only:
47
Hospital
CC – Surgical Benefits – Professional
The following service type codes will be returned with a “CC – Surgical Benefits –
Professional” response:
Eligibility and benefits:
48
50
53
Hospital Inpatient
Hospital Outpatient
Hospital Ambulatory Surgery
Eligibility line only:
CC
Surgical Benefits – Professional
8
Mental Health Requests
When“30-Health Benefit Plan Coverage” is requested, 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 benefits, deductible, out-of-pocket, and outpatient visit limits and accumulators.
Third-Party Administrators
When a benefit is known to be covered by a third-party administrator and the payer’s
information is in the SelectHealth system, the payer name and contact information will be
returned. If benefits are not covered and no third-party information is returned, please
have the member contact his or her Human Resources department or insurance agent.
Eligibility and Benefit Dates
When a request is made, only the eligibility dates for the plan period will be returned. If
the member has open eligibility and there is no termination date in the system, only the
eligibility start date will be returned.
If an inquiry is made on a terminated policy, the termination date and eligibility will be
returned. If an inquiry is made on a policy that has not yet become active, the eligibility
start date will be returned.
If a member is found in the system, but has no past or future eligibility date(s) for the
type of policy requested, the date(s) requested will be returned. If a specific date(s) was
not requested, the request date will be returned. For example, if the request was made for
medical benefits but the member only has a dental policy, the response will indicate that
the member is not active. It will be returned with the dates requested. If possible, verify
that the member has a SelectHealth ID Card. If the card is available, check to see if it
is for medical or dental coverage. If a medical inquiry is performed on a dental policy,
a “patient not found” response will be returned. The same response applies to dental
inquiries performed on medical policies.
Please note that eligibility requests cannot be made for dates older than 24 months. If a
request is made for a date before that period of time, an AAA response will be returned
where AAA03 = 62 “Date of Service Not Within Allowable Inquiry Period.” Also, the
eligibility request cannot span more than 30 days. For example, a request for benefits from
10/01/08 to 11/30/08 would receive an AAA response.
If no date is submitted on the 270, SelectHealth will return benefits using the request date.
9
Limits and Accumulators
Accumulators will be returned where available for the family and individual deductible,
out-of-pocket, and visit limits. For limit amounts, SelectHealth will return an
“EB06 = 22 – Service Year.” For accumulator amounts, SelectHealth will return an
“EB06 = 29 – Remaining.” These amounts represent what the patient has remaining for
these limits during the service year.
Pre-existing Condition (PEC)
If the member is in a PEC waiting period for the date(s) requested, a PEC indicator will
be returned on the 271 with the corresponding PEC end date.
Coordination of Benefits (COB)
COB information will be returned on the 271 for members that have been tracked in the
SelectHealth system with a COB type corresponding to the service type requested. The
COB order and other payer name will be returned in the 271 response. In a tertiary COB
situation, SelectHealth is unable to provide COB information. Please call Member Services
for COB information and order of benefits.
10
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