Standard Companion Guide ASC X12N 270/271: Health Care Eligibility Benefit Inquiry and Response CORE Phase II System Companion Guide Version : 1.0 February 2012 Page 1 of 33
Disclosure Statement The information in this document is subject to change. Changes will be posted via the Network Health website located at: THE 271 RESPONSE RETURNED BY NETWORK HEALTH SHOULD NOT BE INTERPRETED AS A GUARANTEE OF PAYMENT. PAYMENT OF BENEFITS REMAINS SUBJECT TO ALL HEALTH BENEFIT PLAN TERMS, LIMITS, CONDITIONS, EXCLUSIONS AND THE MEMBER S ELIGIBILITY AT THE TIME SERVICES ARE RENDERED Page 2 of 33
Preface This Companion Guide to the ASC X12N Technical Report Type 3 guides adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Network Health Insurance Plan. The following information is intended to serve as a companion document to the HIPAA ASC X12N 270/271 (005010X279A1) Implementation Guide for Eligibility Benefits Inquiry. This companion document supplements, but does not exceed any requirements in the ASC X12N 270/271 (005010X279A1) Implementation Guide. The information describes specific requirements for submitting eligibility and benefit inquiry requests to Network-Health through New England Healthcare Exchange Network (NEHEN) and web services. This document also conforms and is compatible with all CORE Phase I requirements for 270/271 transactions. For more information about CORE Phase II, see http://www.caqh.org/core_phase2.php Page 3 of 33
Table of Contents 1. INTRODUCTION...5 1.1. SCOPE...5 1.2. OVERVIEW...5 1.3. REFERENCES...5 1.4. ADDITIONAL INFORMATION...5 2. GETTING STARTED...5 2.1. TRADING PARTNER REGISTRATION...5 2.2. CERTIFICATION AND TESTING OVERVIEW...6 2.3. TESTING WITH THE NETWORK HEALTH...6 3.1. Real-time Claim Status Request and Response:...6 3.2. RE-TRANSMISSION PROCEDURE...7 3.3. COMMUNICATION PROTOCOL SPECIFICATIONS...7 SYSTEM AVAILABILITY...7 4. CONTACT INFORMATION...8 5. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS...8 5.1. 270 REQUEST...8 5.2. Appendix A...9 6. TRANSACTION SPECIFIC INFORMATION...14 Page 4 of 33
1. INTRODUCTION 1.1. SCOPE Providers and billing services are advised to use the ASC X12N 270/271 (005010X279A1) Implementation Guide as a basis for their submission of Claim Status inquires. This companion document should be used to clarify the CORE Business rules for 270/271 data content requirements, real-time acknowledgment, connectivity and system availability. This document is intended for use with CAQH CORE compliant systems. For additional information on building a CORE compliant system go to http://www.caqh.org. 1.2. OVERVIEW The Health Insurance Portability and Accountability Act Administration Simplification (HIPAA-AS) requires Network Health and all other covered entities to comply with the electronic data interchange standards for health care as established by the Secretary of Health and Human Services. This guide is designed to help those responsible for testing and setting up electronic eligibility transactions and to introduce and provide information about the Network Health s CAQH/CORE Solution for submitting real-time 270/271 transactions. 1.3. REFERENCES 1.3.1. ASC X12 Version 5010A1 Implementation Guides: http://www.wpc-edi.com 1.3.2. Network Health Connect: https://www.healthtrioconnect.com/app/index.page 1.3.3. NEHEN: http://www.nehen.net/ 1.3.4. CAQH/CORE: http://www.caqh.org/benefits.php 1.3.5. Washington Publishing (WSDL): http://www.w3.org/tr/wsdl 1.4. ADDITIONAL INFORMATION Submitters must have Internet (HTTPS) connection capability to submit a CORE 270 request and receive 271 responses. Submitters must possess a valid user ID and password in order to submit inquiries through NEHEN. Only real-time inquiries are supported. 2. GETTING STARTED 2.1. TRADING PARTNER REGISTRATION Page 5 of 33
NEHEN The Trading Partner can email Network Health at EDI@network-health.org requesting VPN setup with Network Health in order to utilize the NEHEN application to send and receive eligibility requests and responses (270/271 transactions). Direct Connection: A signed User Agreement for EDI Intake Form must be completed and sent to the EDI Team prior to direct connectivity set up. To set up for direct connectivity, Trading Partners should contact the EDI Team. 2.2. CERTIFICATION AND TESTING OVERVIEW Network Health is currently seeking CORE Phase I and Phase II certification 2.3. TESTING WITH THE NETWORK HEALTH The Eligibility and Benefit transaction is an inquiry and response transaction and does not result in any data changing upon completion therefore test transactions (ISA15 value of T ) with production data can be sent to our production environment without any negative impact. NEHEN Network Health employs NEHEN for Trading Partner testing of 270 eligibility and responses. Please contact Network Health EDI Team to setup the NEHEN user within its NEHEN egateway configurator website Direct Connection: If you wish to test the eligibility and benefit transaction in Network Health s testing region please contact EDI Team at 781-393-1003 / 781-393-2964 or email at edi@networkhealth.org 3. CONNECTIVITY / COMMUNICATIONS 3.1. Real-time Eligibility Status Request and Response: Real time web services are available for submission of 270 requests. Providers and Trading Partners can log in the web services using their username and password. For further information, Please contact EDI Team at Network Health. Page 6 of 33
3.2. RE-TRANSMISSION PROCEDURE Please follow the instructions within the 271 AAA data segment for information on whether resubmission is allowed or what data corrections need to be made in order for a successful response. 3.3. COMMUNICATION PROTOCOL SPECIFICATIONS Direct Connection: Direct connection supports the Web services for real-time processing of the 270 eligibility file. In order to use the web services, clients will need to follow the standard Web Service-Security specifications of signing the 270 message and encrypting the body with required keys. NEHEN: Trading Partners can also submit 270 eligibility requests through NEHEN http://www.nehen.org PASSWORDS Passwords for direct connection and NEHEN will be supplied upon signing of the trading partner agreement. Passwords will be sent via secure e-mail. SYSTEM AVAILABILITY Network Health s normal business hours for 270/271 EDI processing are as follows all times are EST: Network Health EDI transaction schedule Monday Tuesday Wednesday Thursday Friday Saturday Sunday Submit EDI: anytime Submit EDI: anytime Submit EDI: anytime Submit EDI: 12:00 a.m. 4:30 p.m. Submit EDI: anytime Submit EDI: anytime Submit EDI: anytime * System wide maintenance: 8:00 a.m. 12:00 p.m. Page 7 of 33
4. CONTACT INFORMATION Most questions can be answered by referencing the materials posted at http://www.network-health.org/ EDI Team can be contacted by email - edi@network-health.org, Phone - 781-393-1003 / 781-393-2964 and via Fax - 781-393-2694 from Monday Friday 8 a.m. to 5 p.m. Provider Services should be contacted at 888-257-1985 instead of EDI Customer Service if you have questions regarding the details of a member s benefits. Provider Services is available Monday Friday 8 a.m. to 5 p.m. in provider s time zone. 5. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 5.1. 270 REQUEST 1. The search logic uses a combination of the following data elements: Member ID, Last Name, First Name and Patient Date of Birth (DOB).Cascading search logic will go through the criteria supplied and attempt to find a match. If a match is not found or multiple matches are found, a 271 response will be sent indicating to the user, if possible, what criteria needs to be supplied to find a match. If policy number is sent in the request it will be used as a tie breaker should there be multiple plans for the member. The following table describes the data received for each search scenario that will be supported. If the necessary data elements are not sent in to satisfy one of the below scenarios a 271 AAA 75 error will be returned and a subsequent 270 request with the required additional data elements will need to be sent in. SCENARIO Patient/Member ID Last Name First Name Patient DOB 1 x x x x 2 x x x 3 x x x 4 x x 5 x x x 6 x x x 2. Network Health complies with the X12 Technical Report Type 3 guide and CAQH Core Phase II rules regarding use of the AAA segments for errors and rejections of benefit inquiries. For more information, please visit: http://www.caqh.org/pdf/update/corepiipolicies-rules.pdf Network Health reports the service types defined by the 5010 Technical Report Type 3 guide and CORE; in addition, we have chosen to report additional service types. The complete list of service types is located in Appendix A on page 9. Page 8 of 33
3. Network Health s 271 response does not contain a complete list of all member benefits. If one or more service type codes listed is not returned, the member may not be covered for those services. Some specific Service Types will return benefits for related Service Types as well as for the Service Type submitted on the 270 request. For example, if Service Type 2 (Surgical) is submitted on the 270 request, Network Health will return the following Service Types: 2, 5, 8, and 20. Please see Appendix B on Page 11 for a complete list of Service Type groupings. 5.2. Appendix A Service Type Service Type Definition 1 Medical Care Specialist Office Visit 2 Surgical 3 Diagnostic Lab 4 Diagnostic X-ray 6 Radiation Therapy 5 Anesthesia Additional Outpatient Surgery, may also return Office Visit Surgery and Outpatient Hospital Services 8 Surgical Assistance 12 13 18 20 30 Durable Medical Equipment Purchase Ambulatory Service Center Facility Durable Medical Equipment Rental Second Surgical Opinion Health Benefit Plan Coverage 33 Chiropractic Outpatient Hospital or Outpatient Surgery Non Routine Office Visit 35 Dental Care Dental Benefit or Vendor Name 40 Oral Surgery Medical and/or Dental Benefit and/or Vendor Name 42 Home Health Care 45 Hospice Facility Charge 47 Hospital Outpatient Hospital 48 Hospital - Inpatient Inpatient Hospital Room and Board 50 Hospital - Outpatient Outpatient Surgery Page 9 of 33
51 52 53 Hospital - Emergency Accident Hospital - Emergency Medical Hospital - Ambulatory Surgical 62 MRI/CAT Scan 65 Newborn Care 68 Well Baby Care 73 Diagnostic Medical 76 Dialysis ER ER Outpatient Surgery and may also return Outpatient Hospital Services Inpatient Newborn Care and may also return Outpatient Newborn Care Diagnostic Medical Hospital Outpatient and may also return Diagnostic Medical Outpatient Services 78 Chemotherapy 80 Immunizations 81 Routine Physical 82 Family Planning Non Routine Office Visit 83 Infertility 86 Emergency Services ER 88 Pharmacy Specifies the Pharmacy Benefit Manager. 89 Free Standing Prescription Drug 93 Podiatry 98 99 A0 A3 A6 A7 A8 Professional (Physician) Visit/Office Professional (Physician) Visit - Inpatient Professional (Physician) Visit - Outpatient Professional (Physician) Visit - home Psychotherapy Psychiatric - Inpatient Psychiatric - Outpatient Specifies the name of the Pharmacy Benefit Manager PCP Office Visit and may also return Specialist Office Visit Individual Mental Health Office Visit and may also return Individual Mental Health Outpatient Visit Facility Charge Mental Health Individual Outpatient and may also return Mental Health Group Outpatient Page 10 of 33
AD AE AF AG Occupational Therapy Physical Medicine Speech Therapy Skilled Nursing Care AI Substance Abuse Outpatient Substance Abuse AL BG BH MH UC Vision (Optometry) Cardiac Rehabilitation Pediatric Mental Health Urgent Care Individual Mental Health Office Visit and may also return Individual Mental Health Outpatient Visit 5.3. Appendix B Service Type Requested:30-Health Benefit Plan Coverage( Standard 30 Response) Service Types Returned 1 Medical Care 33 Chiropractic 35 Dental Care 47 Hospital 48 Hospital - Inpatient 50 Hospital Outpatient 51 Hospital - Emergency Accident 52 Hospital - Emergency Medical 56 Emergency Services 88 Pharmacy 98 Professional (Physician) Visit/Office AL Vision (Optometry) Page 11 of 33
MH UC Mental Health Urgent Care Service Type Requested: 1- Medical Care Service Types Returned 1 Medical Care 2 Surgical 42 Hospice 76 Dialysis AG DM Skilled Nursing Care Durable Medical Equipment Service Type Requested: 2- Surgical Service Types Returned 2 Surgical 5 Anesthesia 8 Surgical Assistance 20 Second Surgical Opinion Service Type Requested: 47 Hospital Service Types Returned 47 Hospital 51 Hospital - Emergency Accident 52 Hospital - Emergency Medical A0 Professional (Physician) Visit - Outpatient Service Type Requested: 48 Hospital-Inpatient Service Types Returned Page 12 of 33
48 Hospital - Inpatient 99 Professional (Physician) Visit Inpatient Service Type Requested: 50 Hospital-Outpatient Service Types Returned 50 Hospital Outpatient 51 Hospital - Emergency Accident 52 Hospital - Emergency Medical A0 Professional (Physician) Visit - Outpatient Service Type Requested: 68 Well Baby Care Service Types Returned 68 68 Well Baby Care 80 Immunizations BH Pediatric Service Type Requested: 73- Diagnostic Medical Service Types Returned 5 Diagnostic Lab 62 MRI/CAT Scan 73 Diagnostic Medical Service Type Requested: : 86 Emergency Services Service Types Returned 51 Hospital - Emergency Accident 52 Hospital - Emergency Medical 86 Emergency Services 98 Professional (Physician) Visit/Office Page 13 of 33
Service Type Requested: 98 Professional (Physician) Visit - Office Service Types Returned 98 Professional (Physician) Visit - Office Service Type Requested: A9 - Rehabilitation Service Types Returned DM Durable Medical Equipment 12 Durable Medical Equipment Purchase 18 Durable Medical Equipment Rental Service Type Requested: MH Mental Health Service Types Returned MH Mental Health Service Type Requested: 35 Dental Care Service Types Returned 40 Oral Surgery 6. TRANSACTION SPECIFIC INFORMATION The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. The table contains a row for each segment that Network Health has something additional, over and above, the information in the TR3 s. 270 Data Specifications Element Identifier Description ID Min. Max. Usage Reg. Loop Loop Repeat Values ISA ISA01 INTERCHAN GE CONTROL HEADER 1 R Authorization Qualifier ID 2-2 R 00 Page 14 of 33
ISA02 ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 ISA09 ISA10 ISA11 ISA12 ISA13 ISA14 ISA15 ISA16 GS GS01 GS02 Authorization AN 10-10 R Security Qualifier ID 2-2 R Security AN 10-10 R Interchange ID Qualifier ID 2-2 R Interchange Sender ID AN 15-15 R Interchange ID Qualifier ID 2-2 R Interchange Receiver ID AN 15-15 R Interchange Date DT 6-6 R Interchange Time TM 4-4 R Repetition Separator 1-1 R Interchange Control Version ID 5-5 R Interchange Control N0 9-9 R Acknowledgem ent Requested ID 1-1 R Interchange Usage Indicator ID 1-1 R Component Element Separator 1-1 R FUNCTIONAL GROUP HEADER 1 R Functional Identifier ID 2-2 R Application Sender's AN 2-15 R 00 ZZ ZZ NEHEN041 YYMMDD HHMM 00501 0 P, T (Colon) HS Page 15 of 33
Application NEHEN041 GS03 Receiver's AN 2-15 R GS04 Date DT 8-8 R CCYYMMDD GS05 Time TM 4-8 R HHMMSS GS06 GS07 GS08 ST ST01 ST02 ST03 BHT BHT01 Group Control N0 1-9 R Responsible Agency ID 1-2 R Version/ Release/ Industry Identifier AN 1-12 R TRANSACTIO N SET HEADER 1 R Transaction Set Identifier ID 3-3 R Transaction Set Control AN 4-9 R Implementation Convention Reference AN 1-35 R BEGINNING OF HIERARCHIC AL TRANSACTIO N 1 R Structure ID 4-4 R X 005010X279A1 270 005010X279A1 0022 BHT02 Transaction Set Purpose ID 2-2 R BHT04 Date DT 8-8 R CCYYMMDD BHT05 Time TM 4-8 R CCYYMMDD HL INFORMATIO N SOURCE LEVEL 1 R 2000 A >1 13 Page 16 of 33
HL01 HL03 HL04 NM1 NM101 NM102 NM103 NM108 NM109 HL HL01 HL02 HL03 HL04 NM1 NM101 NM102 NM103 ID AN 1-12 R Level ID 1-2 R Child ID 1-1 R INFORMATIO N SOURCE NAME 1 R Entity Identifier ID 2-3 R Entity Type Qualifier ID 1-1 R Name Last or Organization Name AN 1-60 R Qualifier ID 1-2 R AN 2-80 R 2100 A 1 INFORMATIO N RECEIVER LEVEL 1 R 2000B >1 ID AN 1-12 R Parent ID AN 1-12 R Level ID 1-2 R Child ID 1-1 R INFORMATIO N RECEIVER NAME 1 R 2100B 1 Entity Identifier ID 2-3 R Entity Type Qualifier ID 1-1 R Name Last or Organization Name AN 1-60 R 1 20 1 PR 2 Network Health FI NEHEN041 2 1 21 1 1P,2B,36,80,FA,GP,P5, PR 1, 2 Page 17 of 33
NM104 Name First AN 1-35 S NM105 Name Middle AN 1-25 S NM107 Name Suffix AN 1-10 S NM108 NM109 HL HL01 HL02 HL03 HL04 TRN01 Qualifier ID 1-2 R AN 2-80 R SUBSCRIBER LEVEL 1 R 2000C >1 ID AN 1-12 R Parent ID AN 1-12 R Level ID 1-2 R Child ID 1-1 R Trace Type ID 1-2 R 24,34,FI, PI,PP,SV,XV,XX 540,537 3 2 22 0 1 TRN02 TRN03 TRN04 NM1 NM101 NM102 NM103 Reference AN 1-50 R Originating Company Identifier AN 10-10 R Reference AN 1-50 S SUBSCRIBER NAME 1 R 2100C 1 Entity Identifier ID 2-3 R Entity Type Qualifier ID 1-1 R Name Last or Organization Name AN 1-60 R IL 1, 2 Page 18 of 33
NM104 Name First AN 1-35 S NM105 Name Middle AN 1-25 S NM107 Name Suffix AN 1-10 S NM108 NM109 Qualifier ID 1-2 R AN 2-80 R MI Network Health ID MMIS ID REF REF01 Subscriber Additional S 2100C Reference Qualifier ID 2-3 R 18, 1L, 1W, 3H, 6P, CT, EA, EJ, F6, GH, HJ, IG, N6, NQ, SY, Y4 REF02 DMG DMG01 DMG02 Reference AN 1-50 R Subscriber Demographic S 2100C Date Time Period Format Qualifier ID 2-3 S Date Time Period AN 1-35 S DMG03 Gender ID 1-1 S D8 F,M DTP Subscriber Date S 2100C DTP01 DTP02 Date/Time Qualifier ID 3-3 R Date Time Period Format Qualifier ID 2-3 R 102,291 D8 Page 19 of 33
DTP03 SE Date Time Period AN 1-35 R TRANSACTIO N SET TRAILER 1 R SE01 SE02 GE GE01 of Included Segments N0 1-10 R Transaction Set Control AN 4-9 R FUNCTIONAL GROUP TRAILER 1 R of Transaction Sets Included N0 1-6 R GE02 IEA IEA01 Group Control N0 1-9 R INTERCHAN GE CONTROL TRAILER 1 R of Included Functional Groups N0 1-5 R IEA02 Interchange Control N0 9-9 R 271 Data Specifications Element Identifier Description ID ISA INTERCHAN GE CONTROL HEADER Min. Max. Usage Reg. 1 R Loop Loop Repea t Values Page 20 of 33
ISA01 ISA02 ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 ISA09 ISA10 ISA11 ISA12 ISA13 ISA14 ISA15 ISA16 GS GS01 Authorization Qualifier Authorization Security Qualifier Security Interchange ID Qualifier Interchange Sender ID Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Repetition Separator Interchange Control Version Interchange Control Acknowledgem ent Requested Interchange Usage Indicator Component Element Separator FUNCTIONAL GROUP HEADER Functional Identifier ID 2-2 R 00 AN 10-10 R Expected Value- 10 spaces ID 2-2 R 00 AN 10-10 R Expected Value- 10 spaces ID 2-2 R ZZ AN 15-15 R ID 2-2 R ZZ AN 15-15 R NEHEN041 DT 6-6 R YYMMDD TM 4-4 R HHMM 1-1 R Expected Value: ^ (Caret) ID 5-5 R 00501 N0 9-9 R ID 1-1 R 0 ID 1-1 R P, T 1-1 R (Colon) 1 R ID 2-2 R HB Page 21 of 33
GS02 GS03 Application Sender's Application Receiver's AN 2-15 R NEHEN041 AN 2-15 R GS04 Date DT 8-8 R CCYYMMDD GS05 Time TM 4-8 R HHMMSS GS06 Group Control N0 1-9 R GS07 GS08 ST ST01 ST02 ST03 BHT BHT01 BHT02 Responsible Agency Version/ Release/ Industry Identifier TRANSACTIO N SET HEADER Transaction Set Identifier Transaction Set Control Implementation Convention Reference BEGINNING OF HIERARCHIC AL TRANSACTIO N Structure Transaction Set Purpose ID 1-2 R X AN 1-12 R 005010X279A1 1 R ID 3-3 R 271 AN 4-9 R AN 1-35 R 005010X279A1 1 R ID 4-4 R 0022 ID 2-2 R 11 BHT03 Reference AN 1-50 R Page 22 of 33
BHT04 Date DT 8-8 R CCYYMMDD BHT05 Time TM 4-8 R CCYYMMDD HL HL01 HL03 HL04 NM1 NM101 NM102 NM103 NM108 NM109 PER PER01 Source Level ID Level Child INFORMATIO N SOURCE NAME Entity Identifier Entity Type Qualifier Name Last or Organization Name Qualifier Source contact Contact Function 1 R 2000A 1 AN 1-12 R 1 ID 1-2 R 20 ID 1-1 R 1 1 R 2100A 1 ID 2-3 R PR ID 1-1 R 2 AN 1-60 R Network Health ID 1-2 R PI AN 2-80 R 245,537,540 S 2100A 1 ID 2-2 R IC PER02 Name AN 1-60 S Expected Value: E- Business Department PER03 Communication Qualifier ID 2-2 S EM PER04 Communication AN 1-256 S Expected Value: edi@network-health.org Page 23 of 33
HL HL01 HL02 HL03 HL04 NM1 NM101 NM102 NM103 INFORMATIO N RECEIVER LEVEL ID Parent ID Level Child INFORMATIO N RECEIVER NAME Entity Identifier Entity Type Qualifier Name Last or Organization Name 1 R 2000B 1 AN 1-12 R 2 AN 1-12 R 1 ID 1-2 R 21 ID 1-1 R 1 1 R 2100B 1 ID 2-3 R 1P,2B,36,80,FA,GP,P5, PR ID 1-1 R 1, 2 AN 1-60 R NM104 Name First AN 1-35 S NM105 Name Middle AN 1-25 S NM107 Name Suffix AN 1-10 S NM108 NM109 HL HL01 HL02 HL03 Qualifier SUBSCRIBER LEVEL ID Parent ID Level ID 1-2 R 24,34,FI, PI,PP,SV,XV,XX AN 2-80 R 540,537 1 S 2000C 1 AN 1-12 R 3 AN 1-12 R 2 ID 1-2 R 22 Page 24 of 33
HL04 TRN TRN01 TRN02 TRN03 TRN04 NM1 NM101 NM102 NM103 Child Subscriber Trace Trace Type Reference Originating Company Identifier Reference SUBSCRIBER NAME Entity Identifier Entity Type Qualifier Name Last or Organization Name ID 1-1 R 0 S 2000C 3 ID 1-2 R 2 AN 1-50 R AN 10-10 R AN 1-50 S 1 R 2100C 1 ID 2-3 R IL ID 1-1 R 1 AN 1-60 R NM104 Name First AN 1-35 S NM105 Name Middle AN 1-25 S NM107 Name Suffix AN 1-10 S NM108 NM109 Qualifier ID 1-2 R MI AN 2-80 R N3 Subscriber Address S 2100C 1 Page 25 of 33
N301 Address AN 1-55 R N302 Address AN 1-55 S N4 Subscriber City, State, ZIP S 2100C 1 N401 City Name AN 2-30 R N402 State or Province ID 2-2 S 22C N403 Postal code ID 3-15 S 51,932 AAA Subscriber Request Validation S 2100C 9 AAA01 Yes/No Condition or Response ID 1-1 R N,Y AAA03 Reject Reason ID 2-2 R 42,57,58,60,62,63,72,73,74 Page 26 of 33
AAA04 Follow Up Action ID 1-1 R C,N,R DMG DMG01 DMG02 Subscriber Demographic Date Time Period Format Qualifier Date Time Period S 2100C 1 ID 2-3 S D8 AN 1-35 S DMG03 Gender ID 1-1 S F,M,U DTP Subscriber Date S 2100C DTP01 DTP02 DTP03 EB EB01 Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Subscriber Eligibility or Benefit Eligibility or Benefit ID 3-3 R 096,102,152,291,307,31 8,340,341,342,343,346, 347,356,357,382,435,44 2,458,472,539,540,636, 771 ID 2-3 R RD8,D8 AN 1-35 R S 2110C 1 ID 1-2 R 1,6,B,L,V EB02 EB03 Coverage Level Service Type ID 3-3 S IND ID 1-2 S 1,2,3,4,5,6,7,8,9,10,11,1 2,13,14,15,16,17,18,19, 20,21,22,23,24,25,26,27,28,30,32,33,34,35,36,3 7,38,39,40,41,42,4,44,4 5,46,47,48,49,50,51,52, 53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,6 8,69,70,71,72,73,74,75, Page 27 of 33
EB04 EB05 EB07 EB11 EB12 Insurance Type Plan Coverage Description Monetary Amount Yes/No Condition or Response Yes/No Condition or Response 76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,A 0,A1,A2,A3,A4,A5,A6, A7,A8,A9,AA.AB,AC, AD,AE,AF,AG,AF,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,BQ,BR,BS,BT,BU, BV,BW,BX,BY,BZ,C1, CA,CB,CC,CD,CE,CF, CG,CH,CI,CJ,CK,CL,C M,CN,CO,CP,CQ,DG, DM,DS,GF,,GY,IC,MH,NI,ON,PT,PU,RN.RT, TC,TN,UC ID 1-3 S C1,MC AN 1-50 S R 1-18 S ID 1-1 S N,U,Y ID 1-1 S N,U,W,Y MSG Message Text S 2110C 10 MSG01 Free-form Message Text AN 1-26 R MSG Message Text S 2110C 10 MSG01 Free-form Message Text AN 1-26 R LS Loop Header S LS 1 LS01 NM1 NM101 NM102 NM103 Loop Identifier Subscriber Benefit Related Name Entity Identifier Entity Type Qualifier Name Last or Organization AN 1-4 R S 2120C 1 ID 2-3 R P3 ID 1-1 R 1,2 AN 1-60 R Page 28 of 33
Name NM104 Name First AN 1-35 S NM105 Name Middle AN 1-25 S NM107 Name Suffix AN 1-10 S NM108 NM109 N3 N301 N302 N4 Qualifier Subscriber Benefit Related Entity Address Address Address Subscriber Benefit Related Entity City, State, ZIP ID 1-2 R FI,XX AN 2-80 R 537 AN 1-55 R AN 1-55 S N401 City Name AN 2-30 R N402 State or Province S 2120C 1 S 2120C 1 ID 2-2 S 22C N403 Postal ID 3-15 S 51,932 N404 Country ID 2-3 S N405 N406 N407 PER PER01 Location Qualifier Location Identifier Country Subdivision Subscriber Benefit Related Entity contact Contact Function PER02 Name AN 1-60 S PER03 Communication Qualifier ID 1-2 S RJ AN 1-30 S DOD1 ID 1-3 S 5 S 2120C 1 ID 2-2 R IC ID 2-2 S ED,EM,FX,TE,UR,WP Page 29 of 33
PER04 PER05 PER06 PER07 PER08 Communication Communication Qualifier Communication Communication Qualifier Communication AN 1-256 S ID 2-2 S AN 1-256 S ID 2-2 S AN 1-256 LE Loop Trailer S LS 1 LE01 SE Loop Identifier TRANSACTIO N SET TRAILER S AN 1-4 R 1 R ED,EM,FX,TE,UR,WP PER06 ED,EM,FX,TE,UR,WP PER06 SE01 SE02 GE GE01 of Included Segments Transaction Set Control FUNCTIONAL GROUP TRAILER of Transaction Sets Included N0 1-10 R AN 4-9 R 1 R N0 1-6 R GE02 Group Control N0 1-9 R IEA IEA01 INTERCHAN GE CONTROL TRAILER of Included Functional Groups 1 R N0 1-5 R Page 30 of 33
IEA02 Interchange Control N0 9-9 R 271 RESPONSE Disclaimer: provided in a 271 is not a guarantee of payment or coverage in any specific amount. Actual benefits depend on various factors, including compliance with applicable administrative protocols; date(s) of services rendered and benefit plan terms and conditions. The 271 response may not be exclusively for the payer ID that was received in the 270 request. Sample 270 ISA*00* *00* *ZZ*NEHEN041 *ZZ*NEHEN9999900501*110715*1338* *00501*000000110*0*T*:~ GS*HS*NEHEN041*NEHEN9999999999*123456*1123*110*X*005010X279A2~ ST*270*123456789*005010X279A1~ BHT*0022*13*NWH20110715133848*20110715*848~ HL*1**20*1~ NM1*PR*2*Network Health*****PI*NEHEN041~ HL*2*1*21*1~ NM1*PR*2*Network Health*****PI*NEHEN041~ HL*3*2*22*0~ NM1* LAST*FIRST ****MI*HPP01245600~ DTP*291*D8*20110715~ EQ*30~ SE*12*123456789~ GE*1*123456789~ IEA*1*123456789~ Sample 271 ISA*00* *00* *ZZ*NEHEN041 *ZZ*NEHEN001 *130214*1104* *00501*007566921*0*P* ~ GS*HB*NEHEN041*00000003R*20130214*1104*7566875*X*005010X279A1 ~ ST*271*7566840*005010X279A1~ BHT*0022*11*B391.4859126*20130214*110431~ HL*1**20*1~ NM1*PR*2*NETWORK HEALTH OF MA*****PI*NEHEN041~ HL*2*1*21*1~ NM1*1P*1*John*DOE****XX*123456789~ Page 31 of 33
HL*3*2*22*0~ TRN*2*B391.4859126*9182736450~ NM1*IL*1*John*Doe*A***MI*N00111111~ N3*77 Springfield ST~ N4*Springfield*MA*01151~ DMG*D8*19830720*F~ DTP*356*D8*20120901~ DTP*357*D8*21001231~ EB*1*IND*30*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*30*****0~ EB*B*IND*30****0~ EB*C*IND*30***22*0~ EB*1*IND*1*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*1*****0~ EB*B*IND*1****0~ EB*I*IND*33*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*33*****0~ EB*B*IND*33****0~ EB*I*IND*35*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*35*****0~ EB*B*IND*35****0~ EB*1*IND*47*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*47*****0~ EB*B*IND*47****250~ EB*1*IND*86*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*86*****0~ EB*B*IND*86****100~ EB*1*IND*88*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*88*****0~ EB*B*IND*88****0~ EB*1*IND*98*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*98*****0~ EB*B*IND*98****15~ MSG*PCP~ EB*1*IND*98*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*98*****0~ EB*B*IND*98****22~ MSG*SPECIALIST~ EB*1*IND*AL*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*AL*****0~ EB*B*IND*AL****20~ MSG*OPTOMETRIST~ EB*1*IND*AL*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*AL*****0~ EB*B*IND*AL****22~ MSG*NEUROLOGIST~ Page 32 of 33
EB*1*IND*MH*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*MH*****0~ EB*B*IND*MH****15~ MSG*OUTPATIENT~ EB*1*IND*MH*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*MH*****0~ EB*B*IND*MH****250~ MSG*INPATIENT~ EB*1*IND*UC*C1*COMMONWEALTH CARE PLAN TYPE III~ EB*A*IND*UC*****0~ EB*B*IND*UC****0~ EB*L~ LS*2120~ NM1*P3*1*John*Doe*A***XX*101010101010~ N3*health Care Center*12345 Springfield St~ N4*Springfield*MA*01151~ LE*2120~ SE*70*7566840~ GE*1*7566875~ IEA*1*007566921~ IMPLEMENTATION CHECKLIST The implementation check list will vary depending on your choice of connection; Direct Connect or a web service. However, a basic check list would be to: 1. Establish connectivity 2. Send test transactions 3. If testing succeeds, proceed to send production transactions TRANSMISSION EXAMPLES Please refer to Page 5 above, which points to the appropriate website for Washington Publishing where the reader can view the Implementation Guide, which contains various transmission examples. Page 33 of 33