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 Medical Care 2 Surgical 4 Diagnostic X-Ray (Minor diagnostic benefit) 5 Diagnostic Lab (Minor diagnostic benefit) 7 Anesthesia 11 Used Durable Medical Equipment 12 Durable Medical Equipment Purchase 13 Ambulatory Service Center Facility 18 Durable Medical Equipment Rental 23 Diagnostic Dental 24 Periodontics 25 Restorative 26 Endodontics 27 Maxillofacial Prosthetics 28 Adjunctive Dental Services 30 Health Benefit Plan Coverage 33 Chiropractic 4
34 Chiropractic Office Visits 35 Dental Care 36 Dental Crowns 37 Dental Accidents 38 Orthodontics 39 Prosthodontics 40 Oral Surgery 41 Routine (preventive) Dental 42 Homecare 44 Home Health Visits 47 Hospital 48 Hospital Inpatient 49 Hopsital Room and Board 50 Hospital Outpatient 52 Hospital Emergency Medical (ER Benefits) 53 Hospital Ambulatory Surgical 54 Long-Term Care 56 Medically Related Transportation 59 Ambulance 62 MRI/CAT Scan 66 Pathology 68 Well Baby Care 69 Maternity 73 Diagnostic Medical 75 Prosthetic Device 77 Otological Exam 80 Immunizations 81 Routine Physical 82 Family Planning 86 Emergency Services Professional 88 Pharmacy 94 Podiatry Office Visits 97 Anesthesiologist 98 Professional (Physician) Visit Office A4 Psychiatric A6 Psychotherapy A8 Psychatric Outpatient AD Occupational Therapy AF Speech Therapy AI Substance Abuse AL 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 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 6
Eligibility line only: 30 Health Benefit Plan Coverage 1 Medical Care 47 Hospital Benefits 35 Dental Care MH 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 Diagnostic Dental 24 Periodontics 25 Restorative 26 Endodontics 27 Maxillofacial Prosthetics 28 Adjunctive Dental Services 35 Dental Care 36 Dental Crowns 38 Orthodontics 39 Prosthodontics 41 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 Hospital Inpatient 50 Hospital Outpatient 52 Hospital Emergency Medical 98 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 Hospital Inpatient 50 Hospital Outpatient 52 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 Hospital Inpatient 50 Hospital Outpatient 53 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 2011, 2012 SelectHealth. All rights reserved. 1740 01/12