Healthcare Eligibility Benefit Inquiry and Response. 270/271 Companion Guide

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Brice Richards
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1 Healthcare Eligibility Benefit Inquiry and Response 270/271 Companion Guide

2 Table of Contents Purpose...1 Preparation and Testing Requirements...1 Contact Information...1 System Availability...1 Batch and Real Time...2 SelectHealth Eligibility Response (271)...2 Member Search...2 Patient Not Found Response...2 Multiple Members Found Response...2 Subscriber and Dependent Loops...3 Eligibility and Benefit Information...3 In-Plan Network Indicator...3 Service Type Codes...3 EQ Codes Durable Medical Equipment Purchase Durable Medical Equipment Rental Health Benefit Plan Coverage...5 Dental Requests Dental Care Dental Accident Oral Surgery Long-Term Care Emergency Services...6 Mental Health Requests...6 Third-Party Administrators...6 Eligibility and Benefits Dates...7 Limits and Accumulators...8

3 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 Implementation Guide and is used to more accurately define the response that you will receive. Please refer to the Implementation Guide for information on definitions, loops, segments, elements, data structure, etc. For more information on the Implementation Guide, visit the Washington Publishing Company at Preparation and Testing Requirements To initiate participation in the eligibility benefit inquiry and response, please call the our EDI department at You will need to provide the trading partner number and name in order for the transaction to be established in the system. Our trading partner number can also be obtained from the EDI team. The team will inform the trading partner when the set up is complete and transactions can be sent. Contact Information SelectHealth Member Services Weekdays 7:00 a.m. to 8:00 p.m. Salt Lake area: Saturdays 9:00 a.m. to 2:00 p.m SelectHealth EDI Department Salt Lake area: Weekdays 8:00 a.m. to 5:00 p.m. Fax: System Availability Our 270/271 transaction is available 24 hours, seven days a week. Any planned downtimes will be communicated to Utah Health Information Network (UHIN) and trading partners in advance. If a trading partner has difficulty receiving a response from us, please call

4 Batch and Real Time A 270 inquiry may be sent using batch or real-time. We 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 we will utilize the 271 to respond to eligibility requests (270). Also, this section contains information that may help providers troubleshoot issues when an error response is returned. Member Search You must provide at least three of the following qualifiers to identify a member: subscriber ID, last name, first name, or date of birth. If at least three of these qualifiers are not present in the 270, an AAA response will be returned. AAA03 will equal 15-Required application data missing. If the Social Security number is provided on the 270, we may use it to locate the member. Patient Not Found Response A patient not found response, AAA03 = 67, may be the result of several factors. If only three identifiable pieces of information are sent, and one is spelled differently in our system, a patient not found response may be returned. Verify that the submitted information is accurate. If possible, please check with the member to see if he or she 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 assist in locating the member. Multiple Members Found Response A multiple members found response, AAA03 = 68, may be the result of insufficient information to determine the member. If you receive this response and only three identifiable pieces of information were sent, try obtaining more information from the member. If the member has dual coverage through SelectHealth, please call Member Services at (Salt Lake area) or for eligibility and benefit information. 2

5 Subscriber and Dependent Loops We offer 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, we 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, we will return the correct ID in the NM109 element of the subscriber loop. We will also return the original ID in the REF02 element in the patient loop using the REF01 = Q4 qualifier. 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 in-plan network or out-of-plan network. We are only returning in-plan network benefits and eligibility at this time. Any noncovered response is for inplan networks only and does not preclude the member from having covered out of plan network benefits and eligibility. Please call Member Services at (Salt Lake area) or for out of plan network 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. Also, any visit limits will be returned when available. EQ Codes SelectHealth will provide a specific participating benefit response to the following EQ codes: 2 Surgical 4 Diagnostic X-Ray (Minor diagnostic benefit) 5 Diagnostic Lab (Minor diagnostic benefit) 7 Anesthesia 12 Durable Medical Equipment Purchase 18 Durable Medical Equipment Rental 23 Diagnostic Dental 3

6 24 Periodontics 25 Restorative 26 Endodontics 27 Maxillofacial Prosthetics 28 Adjunctive Dental Services 30 Health Benefit Plan Coverage 33 Chiropractic 35 Dental Care 36 Dental Crowns 37 Dental Accidents 38 Orthodontics 39 Prosthodontics 40 Oral Surgery 41 Routine (preventive) Dental 42 Homecare 48 Hospital Inpatient 50 Hospital Outpatient 52 Hospital Emergency Room (ER Benefits) 53 Hospital Ambulatory Surgical 54 Long-Term Care 56 Medically Related Transportation 59 - Ambulance 69 Maternity 80 Immunizations 82 Family Planning 86 Emergency Services 88 Pharmacy 98 Professional (physician) Visit Office A4 Mental Health AD Occupational Therapy AE Physical Therapy AI Substance Abuse AL Vision 12 Durable Medical Equipment Purchase Please note that certain DME items are not subject to the annual DME maximum amount on some plans. Please contact Member Services with questions. 18 Durable Medical Equipment Rental Please note that certain DME items are not subject to the annual DME maximum amount on some plans. Please contact Member Services with questions. 4

7 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: 12 Durable Medical Equipment Purchase 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 Eligibility line only: 30 Health Benefit Plan Coverage A4 Psychiatric Dental Requests No dental service type codes will be returned in a 30-Health Benefit Plan Coverage response. A specific dental code or the 35-Dental Care inquiry must be sent in a 270 request in order to receive dental eligibility and benefits. 35 Dental Care The following service type codes will be returned with a 35-Dental Care response: Eligibility and benefit lines: 23 Diagnotic 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 5

8 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 at (Salt Lake area) or 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 at (Salt Lake area) or Long Term Care Long-term care will contain benefits for long-term acute care only. Please call Member Services at (Salt Lake area) or for inquiries regarding skilled nursing or hospice. 86 Emergency Services An emergency services response will include the following benefit information: Primary care provider office visit benefits Intermountain InstaCare SM facilities, urgent care facilities benefits Intermountain KidsCare SM facilities benefits Intermountain ExpressCare SM clinics benefits Deductible limits and accumulators Out-of-pocket limits and accumulators Mental Health Requests When a 30-Health Benefit Plan Coverage is requested, only the eligibility line of A4 Psychiatric will be returned. If specific mental health benefits are needed, an A4 Psychiatric request or an AI Substance Abuse request must be sent in a 270 inquiry. The A4 and AI 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 administer and the payers information is in our 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 broker. 6

9 Benefits with possible third-party administrators: 88 Pharmacy 33 Chiropractic 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 A4 Mental Health AI Substance Abuse AL Vision Eligibility and Benefit Dates Eligibility dates will be returned for the plan period for which the request was made. If the member has open eligibility where there is no termination date in our system, only the eligibility start date will be returned. If an inquiry is made on a terminated policy, the term 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 date the request was made will be returned. For example, if the request was made for medical benefits, but the member has a dental only policy, the response will indicate that the member is not active. It will be returned with the dates requested. If possible, please check with the member to see if they have 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 past. 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 7

10 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. 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 SelectHealth. All rights reserved /10

Benefit Name Domestic In Network Out of Network. Benefit Name Domestic In Network Out of Network. 30% Coinsurance Subject to Deductible

Benefit Name Domestic In Network Out of Network. Benefit Name Domestic In Network Out of Network. 30% Coinsurance Subject to Deductible Excellus BluePPO $5/$45/$90 Integrated Rx Benefit Time Period: 01/01/2019-12/31/2019 Thompson Health General Cost Sharing Expenses Deductible - Single $1,350 $1,350 $2,700 Deductible - Family $2,700 $2,700