Transaction Guide Arizona Physicians IPA (APIPA) Eligibility
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1 Healthcare Point-of-Service Transactions VeriFone TRANZ Terminals Transaction Guide Arizona Physicians IPA (APIPA) Eligibility February 13, 2014 Overview This transaction allows you to verify a patient s eligibility status and benefits for APIPA for a single date of service. Disclaimer: The provided information is not a guarantee of coverage. Actual benefits are determined only when the claim is received. Note, certain procedures may require pre-approval. Date of Service Restrictions Any date on file. If no date is entered, press <Enter> to send the current date of service. Special Considerations This payer accepts entry of the provider s National Provider Identifier (NPI) or tax ID. To Enter Letters 1. Press the number key on which the letter appears. 2. Press <Alpha> once, twice, or three times, until the letter appears. 3. Special characters are on the * and # keys. Q and Z are on key 1. Other Usage Tips To print a list of transactions on each key, press <Func> then 2. Request Step: POS Display: Enter: 1 idle 4 (idle prompt AZV) 2 payer menu 1 (APIPA) 3 PROVIDER ID/TAX ID inquiring provider s National Provider Identifier (NPI) or tax ID <Enter> (skips if defaulted) 4 MEMBER ID APIPA subscriber ID <Enter> 5 LAST NAME last name <Enter> 6 FIRST NAME first name <Enter> 7 DOB MMDDCCYY date of birth (mmddccyy) <Enter> 8 SERVICE TYPE Service Type <Enter> See Service Types. 9 DOS MMDDYY date of service (mmddyy) <Enter> or just <Enter> for today s date Response The following section describes each section of information that your payer can return. Individual responses can vary in content. For a detailed dictionary of response data, see the POS v4 Standard Eligibility Response Dictionary. To reprint the last response, press <Func> then 1. Page 1 of 5
2 Input Information The information you entered in your request. APIPA Information Basic information about the transaction, such as: The Submit ID used for tracking Benefit Indicator: Y = Benefit information exists N = No benefit information exists P = Pending Medicare Indicator: NA = Unable to determine Medicare coverage Other Payer Indicator: NA = Unable to determine other payer coverage Information Source Information about the payer, such as primary ID and name. Information Source Contact Payer contact information. Information Receiver Information about the requesting provider, such as primary ID and name. Information Receiver Contact Requesting provider contact information, such as phone numbers or addresses. Eligibility or 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 or benefit type to which the section applies. Your response can include the following sections: Active Coverage Inactive Benefit Disclaimer Note: A row of all dashes designates the beginning of another section of data of the same eligibility/benefit type as the preceding section. Information for each type of eligibility status or benefit section can include: Coverage type Service types 1 Applicable dollar amount or percentage Insurance type 2 Plan coverage information Benefit period Benefit quantity Authorization or certification required In-network indicator Product or service ID Procedure Modifiers Health care service delivery details Additional identifiers Benefit-specific eligibility dates Limitations Information used to determine eligibility Benefit-related entity and entity contact information 1 see Service Types (HIPAA) 2 see Insurance Types (HIPAA) Subscriber Information about the subscriber. Includes: The transaction audit (trace) numbers and origins The subscriber s primary ID Demographic information, such as name, date of birth, gender; returned when the subscriber is the patient Subscriber identification numbers other than the primary ID Eligibility or benefit dates. Dates can also appear in the Eligibility/Benefit section Page 2 of 5
3 Service Types 1 Medical Care 2 Surgical 3 Consultation 4 Diagnostic X-Ray 5 Diagnostic Lab 6 Radiation Therapy 7 Anesthesia 8 Surgical Assistance 9 Other Medical 10 Blood Charges 11 Used Durable Medical Equipment 12 Durable Medical Equipment Purchase 13 Ambulatory Service Center Facility 14 Renal Supplies in the Home 15 Alternate Method Dialysis 16 Chronic Renal Disease (CRD) Equipment 17 Pre Admission Testing 18 Durable Medical Equipment Rental 19 Pneumonia Vaccine 20 Second Surgical Opinion 21 Third Surgical Opinion 22 Social Work 23 Diagnostic Dental 24 Periodontics 25 Restorative 26 Endodontics 27 Maxillofacial Prosthetics (MFP) 28 Adjunctive Dental Services 30 Health Benefit Plan Coverage 32 Plan Waiting Period 33 Chiropractic 34 Chiropractic Office Visits 35 Dental Care 36 Dental Crowns 37 Dental Accident 38 Orthodontics 39 Prosthodontics 40 Oral Surgery 41 Routine (Preventive) Dental 42 Home Health Care 43 Home Health Prescriptions 44 Home Health Visits 45 Hospice 46 Respite Care 47 Hospital 48 Hospital 49 Hospital Room and Board 50 Hospital 51 Hospital Emergency Accident 52 Hospital Emergency Medical 53 Hospital Ambulatory Surgical 54 Long Term Care 55 Major Medical 56 Medically Related Transportation 57 Air Transportation 58 Cabulance 59 Licensed Ambulance 60 General Benefits 61 In vitro Fertilization 62 MRI/CAT Scan 63 Donor Procedures 64 Acupuncture 65 Newborn Care 66 Pathology 67 Smoking Cessation 68 Well Baby Care 69 Maternity 70 Transplants 71 Audiology Exam 72 Inhalation Therapy 73 Diagnostic Medical 74 Private Duty Nursing 75 Prosthetic Device 76 Dialysis 77 Otological Exam 78 Chemotherapy 79 Allergy Testing Page 3 of 5
4 80 Immunizations 81 Routine Physical 82 Family Planning 83 Infertility 84 Abortion 85 AIDS 86 Emergency Services 87 Cancer 88 Pharmacy 89 Free Standing Prescription Drug 90 Mail Order Prescription Drug 91 Brand Name Prescription Drug 92 Generic Prescription Drug 93 Podiatry 94 Podiatry Office Visits 95 Podiatry Nursing Home Visits 96 Professional (Physician) 97 Anesthesiologist 98 Professional (Physician) Visit Office 99 Professional (Physician) Visit A0 Professional (Physician) Visit A1 Professional (Physician) Visit Nursing Home A2 Professional (Physician) Visit Skilled Nursing Facility A3 Professional (Physician) Visit Home A4 Psychiatric A5 Psychiatric Room and Board A6 Psychotherapy A7 Psychiatric A8 Psychiatric A9 Rehabilitation AA Rehabilitation Room and Board AB Rehabilitation AC Rehabilitation AD Occupational Therapy AE Physical Medicine Code AF AG AH AI AJ AK AL AM AN AO AQ AR B1 B2 B3 BA BB BC BD BE BF BG BH BI BJ BK BL BM BN BP BQ BR BS BT BU BV BW BX Description Speech Therapy Skilled Nursing Care Skilled Nursing Care Room and Board Substance Abuse Alcoholism Drug Addiction Vision (Optometry) Frames Routine Exam Lenses Nonmedically Necessary Physical Experimental Drug Therapy Burn Care Brand Name Prescription Drug - Formulary Brand Name Prescription Drug Non-Formulary Independent Medical Evaluation Partial Hospitalization (Psychiatric) Day Care (Psychiatric) Cognitive Therapy Massage Therapy Pulmonary Rehabilitation Cardiac Rehabilitation Pediatric Nursery Skin Orthopedic Cardiac Lymphatic Gastrointestinal Endocrine Neurology Eye Invasive Procedures Gynecological Obstetrical Obstetrical/ Gynecological Mail Order Prescription Drug: Brand Name Mail Order Prescription Drug: Generic Page 4 of 5
5 BY Physician Visit/Office: Sick BZ Physician Visit/Office: Well C1 Coronary Care CA Private Duty Nursing - CB Private Duty Nursing - Home CC Surgical Benefits - Professional (Physician) CD Surgical Benefits - Facility CE Mental Health Provider - CF Mental Health Provider - CG Mental Health Facility - CH Mental Health Facility - CI Substance Abuse Facility - CJ Substance Abuse Facility - CK Screening X-Ray CL Screening Laboratory CM Mammogram, high risk patient CN Mammogram, low risk patient CO Flu Vaccination CP Eyewear and Eyewear Accessories CQ Case Management DG Dermatology DM Durable Medical Equipment DS Diabetic Supplies GF Generic Prescription Drug - Formulary GN Generic Prescription Drug - Non-Formulary GY Allergy IC Intensive Care MH Mental Health NI Neonatal Intensive Care ON Oncology PT Physical Therapy PU Pulmonary RN Renal Code RT TC TN UC Description Residential Psychiatric Treatment Transitional Care Transitional Nursery Care Urgent Care Error Messages Transaction-related error messages begin with CL, HT, or RH, followed by a number and a line or so of text. Most messages are self-explanatory. For a comprehensive description of all error messages, see the document Dictionary of Transaction Error Messages. Page 5 of 5
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