hipaa transactions: 270/271, 278/278 and 276/ · pdf filehipaa transactions: 270/271, 278/278...
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HIPAA Transactions: 270/271, 278/278 and 276/277
Michigan Department of Community HealthMay 1, 2003
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Agenda
Welcome GlossaryTransaction Overview270/271 Eligibility Benefit Inquiry and Response 278/278 Authorization/Certification Request and Response 276/277 Healthcare Claim Status Request and ResponseQuestions
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Glossary
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GlossaryHIPAA/Industry Term Medicaid Term Description
Claim Invoice A single paper form, or a collection of services by a single billing provider for a single patient, billed at one time.
Service Line Claim Line A single service generally associated with a procedure code.
Replacement Adjustment A billing provider’s request to change a previously submitted claim.
Void/Cancel Adjustment A billing provider’s request to void a previously submitted claim.
Health Care Claim Adjustment
The difference between the billing provider’s usual charges and the paid amount. The reason for the difference is described through the use of Health Care Claim Adjustment Reason Codes.
Subscriber Recipient/Beneficiary The individual who is enrolled in Medicaid and receives services.
Billing/Pay-to Provider Provider A hospital, nursing facility, physician or dentist that submits claims to be reimbursed for care they provide to patients (subscribers).
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HIPAA EDI Terminology
HIPAA ANSI X12 Term Medicaid Term (if applicable)
Description
Transaction The exchange of information between two parties to carry out financial or administrative activities related to health care.
Loop A repeating section in an EDI transaction. Segment A group of related data elements within an EDI transaction. Simple Data Element The smallest unit of information in an EDI transaction. Composite Data Element A more complex unit containing two or more simple data
elements. Delimiter A character used to separate data elements in an EDI
transaction. Qualifier A data element that describes the type of information that is
to follow in an EDI segment.
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Transaction Overview
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HIPAA Transactions
Transactions prior to treatmentEligibility Verification (270/271)Authorization/Referral (278)
Claims and related transactionsClaims (837)Remittances (835)Claim Status (276/277)
Managed care transactionsEnrollment (834)Premium Payment (820)Encounter (837)
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Health CareProviders
Health CareProviders MDCH MDCH
Prior to Treatment Transactions
271 – Eligibility Benefit Response
278 – Authorization/Certification Response
278 – Authorization/Certification Request
270 – Eligibility Benefit Request
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BillingBilling ClaimsAdjudication
ClaimsAdjudication
Health Care Providers MDCH
Claim-Related Transactions
277 – Claim Status Response
835 – Claim Payment
276 – Claim Status Request
837 – Claim
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270/271 Eligibility Benefit Inquiry and Response
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MDCH Eligibility Verification System
MDCH currently contracts with outside entities to manage eligibility verification on behalf of the Department
MDCH provides these contractors with eligibility files and updates on a 6-month, weekly or daily schedule
Eligibility files include information for: Title XIX, Title V, MOMS, and Delta Dental Preferred and Premier beneficiaries
Eligibility files also include: Provider file, Managed Care Provider file, Other Insurance Coverage file and MDCH Carrier file
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MDCH Eligibility Verification System
Medicaid enrolled providers currently request eligibility verification from MDCH contractors through a variety of products, including:
Automated Voice Response System with Voice or Fax Back ResponseElectronic Data Interchange (EDI)
• PC Based Eligibility Verification System (EVS)• Browser Based EVS• Point of Service EVS
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270/271 Overview
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270/271 Overview
The 270 is used by a provider to request eligibility, coverage, and benefit information from a payer
The 271 is used by the payer to respond to a provider’s request for eligibility, coverage, and benefit information
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MDCH 270/271 Transaction
Goal is to implement a HIPAA 271 transaction that:Supports current MDCH eligibility verification business practicesProvides consistency across all MDCH eligibility contractors
Contractors currently receiving MDCH eligibility files and reporting eligibility and benefit information to providers:
MedifaxHDXNetwerkes.com
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270/271 Transaction Detail
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270 Request Transaction StructureST 270
Transaction Set Header
Table 2 -- Detail
2000A — Information Source
2100A — Information Source Name
2000B — Information Receiver
2100B — Information Receiver Name
2000C — Subscriber
2100C — Subscriber Name
2110C — Subscriber Eligibility or Benefit Inquiry Information
2000D — Dependent
2100D — Dependent Name
2110D — Dependent Eligibility or Benefit Inquiry Information
SE 270
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2000A Information Source
MDCHPayer Identification Number (D00111)
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2000B Information Receiver
ProviderProvider Identification Number (Medicaid Provider ID)
Provider Contact Information
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2000C Subscriber
Subscriber name
Subscriber member identification number Medicaid Recipient ID
Subscriber additional identificationSocial Security Number
Subscriber date of birthEligibility, service or admission datesService type code (eligibility request)
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271 Response Transaction StructureST 271
Transaction Set HeaderTable 2 Detail
2000A — Information Source2100A — Information Source Name
2000B — Information Receiver 2100B — Information Receiver Name
2000C — Subscriber2100C — Subscriber Name
2110C — Subscriber Eligibility or Benefit Information2115C — Subscriber Eligibility or Benefit Additional Information2120C — Subscriber Benefit Related Entity Name
2000D — Dependent2100D — Dependent Name
2110D — Dependent Eligibility or Benefit Information2115D — Dependent Eligibility or Benefit Additional Information2120D — Dependent Benefit Related Entity Name
SE 271
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2000A Information Source
MDCHPayer Identification Number (D00111)
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2000B Information Receiver
ProviderProvider Identification Number (Medicaid Provider ID)
Contact Information
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2000C Subscriber
Subscriber name
Subscriber member identification number (Medicaid Recipient ID)
FIA worker load number
FIA case number
FIA county office phone numberPatient account number (if sent in 270)Subscriber address, including county code and nameSubscriber date of birth, gender
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2000C Subscriber (continued)
Eligibility begin and end datesSpecific eligibility or benefit information
Active, Inactive, Spend Down, Limitations, Other or Additional Payer, etc.Coverage Level (Individual, Family, Dependents Only, etc.)Service Type Code (General Benefits, Dental Care, Maternity, Emergency Services, etc.)Insurance Type Code (Medicaid, HMO, Qualified Medicare Beneficiary, Special Low Income Medicare Beneficiary, Medicare Part A, Medicare Part B, Commercial, etc.)Scope, Coverage, Level of Care, Program and Healthy Kids Dental District CodesLong term care co-pay or deductible amounts
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2000C Subscriber (continued)
SMP eligibility authorization on file
CSHCS provider authorized/not authorized
Medicare Health Insurance Claim (HIC) number or other insurance group number (if applicable)
Subscriber benefit related entity name, identification number and contact information
Medicaid, SMP or CSHCS health plan information
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2000D Dependent
Dependent name
Dependent member identification number
Other payer contract number
Other payer policy number
Specific eligibility and benefit information
Benefit coverage dates
Other payer name and telephone number
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Questions and Answers