Companion Guide - Eligibility Inquiry and ... - AmeriHealth.com

AmeriHealth and AmeriHealth Mercy
X12 270/271 Eligibility Companion Guide
Health Care
Eligibility Benefit
Inquiry and
Response
270/271
ASC X12N 270/271 (005010X279A1)

AmeriHealth and AmeriHealth Mercy
X12 270/271 Eligibility Companion Guide
Table of Contents
1. Overview of Document ........................................................................................... 3
2. General Information ............................................................................................... 4
a. Patient Identification ................................................................................................................. 4
b. Dates of Service ........................................................................................................................ 4
c. Transmission Size and Type ................................................................................................... 4
3. Provider Identification ............................................................................................ 5
4. BlueExchange® ..................................................................................................... 5
5. Contact Information ............................................................................................... 5
6. 270 Data Elements ................................................................................................ 6
7. 271 Data Elements .............................................................................................. 12
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X12 270/271 Eligibility Companion Guide
1. Overview of Document
This guide is to be used as a supplement to the 270/271 Health Care Eligibility Benefit
Inquiry version 005010X279A1 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.
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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 ID, 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 1.4.8.2 and 1.4.8.3 in the
HIPAA 5010 Implementation Guide for more information.
‣ The AmeriHealth Patient ID consist of a 3-character alpha prefix, an 8-digit Universal
Subscriber Id, and a 2-digit patient suffix. Ideally the entire ID 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 ID 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, 22248 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.
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X12 270/271 Eligibility Companion Guide
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 ID is not used by AmeriHealth to process 270 requests for our
members
i. National Provider ID, Tax ID and AmeriHealth‟s corporate IDs will be
accepted.
b. The provider ID 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 ID, including alpha prefix, is provided (e.g.
XYZ1234567890). Without the alpha prefix, the patient will be treated as an AmeriHealth
member only.
When the correct patient ID 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 ID,
which begins with “R” and is followed by 8 numeric characters, (e.g. R12345678).
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 ID +
AmeriHealth Plan Code (Always 375) +
Requesting Provider‟s 10-digit AmeriHealth Provider Number
b. Further details are located in the 270 Data Elements 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
1-800-275-2583
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X12 270/271 Eligibility Companion Guide
6. 270 Data Elements
Segment:
Loop:
Level:
Usage:
Notes:
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 Element Summary
Data
Element
ID
BHT02
Element Name
Transaction Set
Purpose Code
Element Note
Enter code value: 13 (Request)
Segment:
Loop:
Level:
Usage:
Notes:
NM1 Information Source Name
2100A
Detail
Required
AmeriHealth business practices require this information.
Data Element Summary
Data Element Name Element Note
Element
ID
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: 54704
Enter code value: 22248 (for AmeriHealth Mercy
member requests ONLY)
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Segment:
Loop:
Level:
Usage:
Notes:
NM1 Information Receiver Name
2100 B
Detail
Required
AmeriHealth business practices require this information.
Data Element Summary
Data
Element
ID
NM101
Element Name
Entity Identifier Code
Element 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 ID + 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 ID, z = 10-digit AmeriHealth
Provider #
Example #1: If the tax id is the only provider
identifier you have:
xxxxxxxxxx123456789375xxxxxxxxxx
Example #2: If the Provider‟s NPI is the only
provider identifier you have:
1234567895xxxxxxxxx375xxxxxxxxxx
Example #3: If the Provider‟s NPI and tax Id are
the only provider identifiers you have:
1234567895123456789375xxxxxxxxxx
Example #4: If all provider identifiers are
available:
12345678951234567893750001234000
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Segment:
TRN Trace
Loop: 2000
Level: Detail
Usage: Situational
Notes: AmeriHealth business practices require this information.
Data Element Summary
Data Element Name Element Note
Element
ID
TRN01 Trace Type Code “1”
Please reference the HIPAA Implementation Guide for all other TRN segment data
elements.
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Segment:
Loop:
Level:
Usage:
Notes:
NM1 Subscriber Name
2100 C
Detail
Required
AmeriHealth business practices require this information.
Data Element Summary
Data Element Name Element Note
Element
ID
NM108 Identification Code Enter code value: MI (Member Identification)
Qualifier
NM109 Identification Code Enter value: Universal Subscriber ID from the
Patient‟s current ID card
Examples:
AmeriHealth PPO – Q1B1234567800
AmeriHealth Traditional – Q1T12345678
AmeriHealth HMO/POS – Q1C9876543200 (Do
not include the 1 character letter that may be at
the end of the ID number)
AmeriHealth Mercy (AMHP) – YXM123456
Out-of-Area – XYZ123 through
XYZ12345678912345 (6 – 17 characters)
FEP – R12345678
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Segment:
Loop:
Level:
Usage:
Notes:
EQ Service Type Code
2110C/D
Detail
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 Element Summary
Data Element Name Element Note
Element
ID
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
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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.)
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7. 271 Data Elements
Segment:
Loop:
Level:
Usage:
Notes:
REF Reference Identification
2100C/D
Detail
Situational
AmeriHealth business practices require this information
when the Patient ID was corrected within the response.
Data Element Summary
Data
Element
ID
REF01
Element Name
Reference Identification
Qualifier
Element 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 ID
Segment:
Loop:
Level:
Usage:
Notes:
INS Insured Benefit
2100C/D
Detail
Required
AmeriHealth business practices require this information
when identifying Patient information was corrected within
the response.
Data Element Summary
Data
Element
ID
INS01
Element Name
Yes/No Condition or
Response Code
Element Note
See HIPAA Implementation Guide
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Data
Element
ID
INS02
Element Name
Individual Relationship
Code
Element Note
See HIPAA Implementation Guide
INS03
INS04
Maintenance Type
Code
Maintenance Reason
Code
Expect value: 001
Expect value: 25
Segment:
Loop:
Level:
Usage:
Notes:
EB Subscriber/Dependent Eligibility or Benefit Information
2110C/D
Detail
Situational
AmeriHealth will populate this segment with the elements
described below when a member is found to have greater
than one active policy.
Data Element Summary
Data
Element
ID
Element Name
Element 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
Segment:
Loop:
Level:
Usage:
Notes:
NM1 Subscriber Benefit Related Entity Contact Information
2120C/D
Detail
Situational
AmeriHealth will populate this segment with the elements
described below when a member is found to have greater
than one active policy.
Data Element Summary
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Data
Element
ID
Element Name
Element 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
Segment:
Loop:
Level:
Usage:
Notes:
NM1 Subscriber Benefit Related Entity Contact Information
2120C/D
Detail
Situational
AmeriHealth business practices require this information
when the identified Patient is an HMO member.
Data Element Summary
Data Element Name Element Note
Element ID
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
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