gary beatty introduction to - ehcca.com
TRANSCRIPT
![Page 1: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/1.jpg)
Gary BeattyPresidentWashington Publishing Company
ChairX12N Insurance Subcommittee
Introduction to 270/271
Health Care EligibilityInquiry/Response
August 20, 2001
![Page 2: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/2.jpg)
270/271 Eligibility Inquiry/Response
Background
ProvidersInformation Receivers
PayersInformation Source
270
271
•Is the Subscriber or Dependent on file?
•What is the eligibility/benefit information?
•No history of benefit usage
![Page 3: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/3.jpg)
270/271 Eligibility Inquiry/Response
Background270 Inquiries
Specific Inquiry Examples
Submitter Type Payer/Plan Benefits RequestedAll provider Types All Medical/Surgical Benefits
and Coverage Conditions
General Inquiries
Submitter Type Payer/Plan Benefits RequestedAmbulatory Surgery Hernia RepairCenter
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
Submitter Type Payer/Plan Benefits RequestedSpecific provider Types
All Benefits Pertinent to Provider Type
Categorical Inquiries
![Page 4: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/4.jpg)
270/271 Eligibility Inquiry/Response
Background271 Reply
Categorical Responses
General 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)
•eligibility status•Maximum benefits (policy limits)•Exclusions•In-plan/out-of-plan benefits•C.O.B. information•Deductible•Co-pays
![Page 5: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/5.jpg)
270/271 Eligibility Inquiry/Response
Background
General Simple Inquiries
Specific Requests: Complex Inquiries
EligibilityRequest/Response
Complexity
![Page 6: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/6.jpg)
270/271 Eligibility Inquiry/Response
UnsupportedBusiness Functions
•Authorization requests
•Certification requirements
•Utilization management/review requirements
278Health Care Services Review
![Page 7: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/7.jpg)
270/271 Eligibility Inquiry/Response
Background
HierarchicalStructure
Payer/Plan (source)HL*1**20*1~
Provider (receiver)HL*2**21*1~
SubscriberHL*3**22*1~
DependentHL*4**23*0~
EligibilityDependentHL*4**23*0~
Eligibility
SubscriberHL*3**22*1~
DependentHL*4**23*0~
Eligibility
![Page 8: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/8.jpg)
270/271 Eligibility Inquiry/Response
Example 270Eligibility Inquiry
ST*270*1234~BHT*0022*13*1*20010820*1330~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~
![Page 9: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/9.jpg)
XML
The GoodXML 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
The Good
![Page 10: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/10.jpg)
XML
The Bad
• A technical specification
• Flexible
• Young and Immature
• No well defined standards
• A replacement for EDI
eXtensible Markup Language (XML)
Yet another problem…
![Page 11: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/11.jpg)
XML
Different and yet the same
A Schema built based on the 270 Implementation Guide
A Schema built based an interpretation
Both XML documents have the identical information, both are well-formed, and yet the second one is not based on a standard whereas the first is based on the 270 implementation guide.
What about X12?
![Page 12: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/12.jpg)
XML
And X12 EDIThe X12 standard represents a very structured, positional format that relies on data elements being in certain positions within a document relative to other data elements.
X12 has spent many years developing many industry-specific guidelines for using the X12 standard.
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*1234~
![Page 13: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/13.jpg)
XML
And X12 Where to go from here?EDI
• Structure
• Standards
• Data Elements
• Implementation Guides
XML
• Well-formed
• Tag Names
• DTD’s/Schemas
Is it possible that EDI is the cornerstone for the XML B2B standards?
![Page 14: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/14.jpg)
HIPAAST*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*1234~
270 Transaction Set
EDI
XML
DEMO
![Page 15: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/15.jpg)
The Comparison
X12N
XML
Size : 1k
Size : 3k
![Page 16: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/16.jpg)
X12 XMLCurrent Excerpt from 270 Implementation Guide
270 Implementation Guide Excerpt with X12 XML
NM1*IL*1*Brown*Jane****MI*345678901~
![Page 17: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/17.jpg)
X12 XML Current Excerpt from 270 Implementation Guide
270 Implementation Guide Excerpt with X12 XML
![Page 18: Gary Beatty Introduction to - ehcca.com](https://reader034.vdocuments.net/reader034/viewer/2022042302/625aafb8d6987d52fa6c3e10/html5/thumbnails/18.jpg)
ConclusionX12 XML
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: