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The Health Care Eligibility/Coverage/Benefit transactions are designed, so that inquiry
submitters (information receivers) can determine whether an Information Source
organization, e.g., payer, employer, HMO, has a particular subscriber
and/or dependent(s).
The data available through these transaction sets can be used to verify an individual's
eligibility or benefits, but they cannot provide a history of benefit use. The
information source organization may provide information about organizations that may have
third party liability for the coordination of benefits.
To accomplish this, two Health Care Eligibility/Coverage/Benefit transaction sets are
used. They are:
Health Care Eligibility/Coverage/Benefit Inquiry (270)
From a submitter (information receiver) to an information source organization
Health Care Eligibility/Coverage/Benefit Information (271)
From an information source organization to an
information receiver
The 270 and 271 transaction sets are designed to take the following entries:
Insurance companies
Health Maintenance Organizations (HMOs)
Preferred Provider Organizations (PPOs)
Health Care Purchasers (i.e., employers)
Professional Review Organizations (PROs)
Social Worker Organizations
Health Care Providers, e.g.,
physicians, hospitals, laboratories
Third-Party Administrators (TPAs)
Health Care Vendors, e.g., practice
management vendors, billing services
Service Bureaus (VANs or VABs), and
Government agencies such as Medicare, Medicaid, and Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS).
LOOP Structure of 270
The following
is the overall structure of the 270 Transaction Set:
Eligibility or Coverage/Benefit Information Source
Subscriber
Dependent
Eligibility or Benefit
Inquiry (Question)
Subscriber
Dependent
Eligibility or benefit Inquiry (Question)
Eligibility or Benefit Inquiry (Question)
HL Segment in 270/271
The 270/271 loop structure utilizes the HL "Hierarchical Level" data segment.
The HL provides four explicitly defined nested loops. Each HL loop's semantic relationship
applies equally to any outer HL or additionally defined inner nested HL loop.
To assist the transaction set implementation in visualizing the assignment and usage of
data segments within each transaction set HL loop, the following tables have been
included. The tables show the data segments and their position assignment within Tables 1
and 2 of the 270 Requested transaction set. Each data segment is then shown with its usage
for the HL level identified.
Note:
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The ASC X12 HL looping structure requires the HL segment to start an HL loop
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The first segment of any loop is mandatory, if any segment that loop is used.
The Hierarchical Level code values are:
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20 |
Eligibility/Coverage/Benefit Information Source
Identifies the payer, maintainer, or source of the eligibility or benefit information. |
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21 |
Eligibility/Coverage/Benefit Information Receiver
Identifies the provider who receives the eligibility or benefit information. |
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22 |
Subscriber
Identifies the employee or group member, or patient who is covered for insurance and to
whom, or on behalf of whom, the insurer agrees to pay benefits. |
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23 |
Dependent
Identifies the person who is affiliated with the subscriber (such as spouse, child, etc.).
if this HL is present, it will identify the parent. |
271
The eligibility or benefit reply information from the information source organization
is contained in the Health care Eligibility/Coverage/Benefit Information (271) transaction
set in an Eligibility or Coverage or Benefit Information "EB" data segment. The
information source can also return other information about eligibility and benefits based
on its business agreement with the inquiry submitter and available information which it
may be able to provide.
The Health Care Eligibility/Benefit Information 271 transaction set supports the
following example business functions.
General Requests
Eligibility Status
Categorial Requests
Maximal Benefits
Exclusions
Pre-Existing Conditions
In Plan/Out of Plan Benefits
C.O.B. Information
Deductible
Co-pays
Specific Requests
Procedure Coverage Dates
Procedure Coverage Maximum Amounts Allowed
Deductible Amounts
Remaining deductible Amounts
Co-Insurance Amounts
Co-Pay Amounts
Coverage Limitation %
Patient Responsibility Amounts
Non-Covered Amounts
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