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Introduction To 270/271: Health Care Eligibility Inquiry/Response

The document discusses the 270/271 eligibility inquiry and response transaction set. It provides background on 270 inquiries from providers to payers requesting eligibility information and 271 responses from payers with the requested eligibility details. It describes the types of general and specific eligibility inquiries that can be submitted, as well as the general and categorical responses that can be returned. It also notes that authorization requests and other business functions are not supported. The document outlines the hierarchical structure used in 270/271 transactions and provides an example 270 eligibility inquiry transaction. It discusses XML and compares it to the existing EDI standard, noting the structured and positional nature of X12 transactions. It suggests X12 implementation guides could define XML schemas and documents in the same way they have defined

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Nikhil Satav
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115 views18 pages

Introduction To 270/271: Health Care Eligibility Inquiry/Response

The document discusses the 270/271 eligibility inquiry and response transaction set. It provides background on 270 inquiries from providers to payers requesting eligibility information and 271 responses from payers with the requested eligibility details. It describes the types of general and specific eligibility inquiries that can be submitted, as well as the general and categorical responses that can be returned. It also notes that authorization requests and other business functions are not supported. The document outlines the hierarchical structure used in 270/271 transactions and provides an example 270 eligibility inquiry transaction. It discusses XML and compares it to the existing EDI standard, noting the structured and positional nature of X12 transactions. It suggests X12 implementation guides could define XML schemas and documents in the same way they have defined

Uploaded by

Nikhil Satav
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Gary Beatty

President
Washington
Publishing
Introduction to
Company
270/271
Chair
X12N Insurance
Health Care
Subcommittee
Eligibility
Inquiry/Response

August 20, 2001


270/271 Eligibility
Inquiry/Response

Background 270

271

Providers Payers
Information Receivers Information Source

•Is the Subscriber or Dependent on file?


•What is the eligibility/benefit information?

•No history of benefit usage


270/271 Eligibility General Inquiries
Inquiry/Response
Submitter Type Payer/Plan Benefits Requested
Background All provider Types All Medical/Surgical Benefits
and Coverage Conditions
270 Inquiries Categorical Inquiries
Submitter Type Payer/Plan Benefits Requested
Specific provider All Benefits Pertinent to
Types Provider Type
Specific Inquiry Examples
Submitter Type Payer/Plan Benefits Requested
Ambulatory Surgery Hernia Repair
Center
D.M.E Wheelchair Rental
Dentist Bonding
Free Standing Lab Diagnostic Lab Service
Hospital Pre-Admission Testing
Nursing Home Physical Therapy Services
Pharmacy Prescription Drugs
Physician Well Baby Coverage
270/271 Eligibility
Inquiry/Response General Responses
•eligibility status
Background •Maximum benefits (policy limits)
271 Reply •Exclusions
•In-plan/out-of-plan benefits
•C.O.B. information
•Deductible
•Co-pays
Categorical Responses
•Procedure coverage dates
•Procedure coverage maximum amount(s) allowed
•Deductible amount(s)
•Remaining deductible amount(s)
•Co-insurance amount(s)
•Co-pay amount(s)
•Coverage limitation percentage
•Patient responsibility amount(s)
•Non-covered amount(s)
270/271 Eligibility Complexity
Inquiry/Response

Background Eligibility
Request/Response

Specific Requests:
Complex Inquiries

General
Simple
Inquiries
270/271 Eligibility
Inquiry/Response

Unsupported •Authorization requests


Business
Functions •Certification requirements
•Utilization
management/review
requirements

278
Health Care Services Review
270/271 Eligibility
Inquiry/Response HL*1**20*1~
Background Payer/Plan (source)
Hierarchical
Structure HL*2**21*1~
Provider (receiver)

HL*3**22*1~ HL*3**22*1~
Subscriber Subscriber

HL*4**23*0~ HL*4**23*0~ HL*4**23*0~


Dependent Dependent Dependent
Eligibility Eligibility Eligibility
270/271 Eligibility
Inquiry/Response
ST*270*1234~
Example 270 BHT*0022*13*1*20010820*1330~
Eligibility Inquiry HL*1**20*1~
NM1*PR*2******PI*123456789~
HL*2*1*21*1~
NM1*1P*2******SV*987654321~
HL*3*2*22*0~
NM1*IL*1*BROWN*JANE****MI*345678901~
EQ*30**FAM~
SE*10*1234~
XML
The Good
XML is a method to:

• Package Information
• Give the information structure
• Convey a semantic meaning
• Designed for speed
• Decreased costs
• Cross Platform extensibility

Sounds wonderful…..
XML
eXtensible Markup Language (XML)
The Bad

• A technical specification
• Flexible
• Young and Immature
• No well defined standards
• A replacement for EDI

Yet another problem…


XML A Schema built based on the 270
Implementation Guide
Different
and yet
the same

Both XML documents


have the identical
information, both
are well-formed, and
yet the second one
is not based on a A Schema built based an interpretation
standard whereas
the first is based on
the 270
implementation
guide.

What about
X12?
XML
And X12 EDI
The X12 standard represents a very
ST*270*1234~BHT structured, positional format that relies on
*0022*13*1*2000 data elements being in certain positions
0329*2158~HL*1*
*20*1~NM1*PR*2 within a document relative to other data
******PI*123456
789~HL*2*1*21*1 elements.
~NM1*1P*2*****
*SV*987654321~
HL*3*2*22*0~NM
1*IL*1*Brown*Ja
ne****MI*345678 X12 has spent many years developing many
901~EQ*30**FAM
~SE*10*1234~ industry-specific guidelines for using the
X12 standard.
XML
And X12 Where to go from here?
EDI
• Structure
• Standards
• Data Elements
• Implementation Guides
Is it possible
that EDI is the
cornerstone for XML
the XML B2B
standards? • Well-formed
• Tag Names
• DTD’s/Schemas
HIPAA 270 Transaction Set
EDI ST*270*1234~BHT*0022*13*1*20000329*2158~HL*1**20*1~NM1*PR*2**
****PI*123456789~HL*2*1*21*1~NM1*1P*2******SV*987654321~HL*3*2
*22*0~NM1*IL*1*Brown*Jane****MI*345678901~EQ*30**FAM~SE*10*123
4~

XML

DEMO
The Comparison
XML
Size : 3k

X12N
Size : 1k
X12 XML
Current Excerpt from 270
Implementation Guide

NM1*IL*1*Brown*Jane****MI*345678901~

270 Implementation Guide Excerpt


with X12 XML
X12 XML Current Excerpt from 270
Implementation Guide

270 Implementation Guide Excerpt


with X12 XML
X12 XML Conclusion

X12 Implementation Guides with the


XML tags identified, approved and
specified can become the definitive
guide to writing standard adhering
schemas and well-formed XML
documents just as the guides have
served the EDI community for the past
21 years as the definitive source for
writing X12 EDI compliant transaction
sets.

Email:

[email protected]

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