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Health Care Eligibility Benefit Inquiry and Response (270 – 271)
Standard Companion Guide
Transaction Information
June 21, 2016
Version 5.0
005010X279A1 Health Care Eligibility Benefit Inquiry and Response
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Express permission to use ASC X12 copyrighted materials within this document has been granted.
© Copyright 2010, 2016 Hewlett Packard Enterprise Development LP
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Disclosure Statement The Kansas Department of Health and Environment (KDHE) is committed to maintaining the integrity and security of health care data in accordance with all applicable laws and regulations. This document is intended to serve as a companion guide to the corresponding Accredited Standards Committee (ASC) X12 005010X279 Health Care Eligibility/Benefit Inquiry and Information Response (270/271), related addenda 005010X279A1, and related errata 005010X279E1.
Disclosure of Medicaid beneficiary eligibility data is restricted under the provisions of the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The provider Medicaid beneficiary eligibility transaction is to be used for conducting Medicaid business only.
This document can be reproduced and/or distributed, but the ownership by Kansas Medicaid must be acknowledged and the contents must not be modified.
Preface Companion guides (CGs) may contain two types of data, instructions for electronic communications with the publishing entity (Communications/ Connectivity Instructions) and supplemental information for creating transactions for the publishing entity while ensuring compliance with the associated ASC X12 IG (Transaction Instructions). Either the Communications/Connectivity component or the Transaction Instruction component must be included in every CG. The components may be published as separate documents or as a single document.
The Communications/Connectivity component is included in the CG when the publishing entity wants to convey the information needed to commence and maintain communication exchange.
The Transaction Instruction component is included in the CG when the publishing entity wants to clarify the IG instructions for submission of specific electronic transactions. The Transaction Instruction component content is limited by ASC X12’s copyright and Fair Use statement.
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Table of Contents Transaction Instruction (TI) .......................................................................... 5
1. TI Introduction ............................................................................................ 5 1.1 Background ............................................................................................ 5
1.1.1 Overview of HIPAA Legislation ..................................................... 5 1.1.2 Compliance According to HIPAA .................................................. 5 1.1.3 Compliance According to ASC X12 .............................................. 5
1.2 Intended Use .......................................................................................... 6 1.3 References............................................................................................. 6
1.3.1 Included ASC X12 Implementation Guides ................................... 6
2. Getting Started ........................................................................................... 7 2.1 Working with the KMAP EDI Department ............................................... 7 2.2 Trading Partner Registration .................................................................. 7 2.3 Testing Overview ................................................................................... 7
3. Testing with the Payer ............................................................................... 7
4. Connectivity with the Payer ....................................................................... 8 4.1 Process Flow ......................................................................................... 8 4.2 Transmission Administrative Procedures ............................................... 8 4.3 Retransmission Procedure ..................................................................... 8 4.4 Communication Protocol Specifications ................................................. 8 4.5 Passwords ............................................................................................. 8
5. Contact Information ................................................................................... 9 5.1 EDI Customer Service ............................................................................ 9 5.2 Provider Service Number ....................................................................... 9 5.3 Relevant Websites ................................................................................. 9
6. Control Segments/Envelope Definitions for 270/271 Transactions .......10 6.1 ISA – Interchange Control Header Segment .........................................10 6.2 GS – Functional Group Header .............................................................10 6.3 ST – Transaction Set Header ................................................................10
7. Payer Specific Business Rules and Limitations......................................11
8. Acknowledgements ...................................................................................13 8.1 Report Inventory ...................................................................................13
9. Trading Partner Agreements .....................................................................14 9.1 Trading Partner ......................................................................................14
10. 270 Health Care Eligibility Inquiry – Transaction Specific ......................15
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10.1 270 Health Care Eligibility Benefit Inquiry ............................................15 10.2 271 Health Care Eligibility Response – Transaction Specific Information ...................................................................................................................15
11. Appendix ....................................................................................................19 11.1 Implementation Checklist ....................................................................19 11.2 Business Scenarios .............................................................................19 11.3 Transmission Examples ......................................................................19 11.4 Frequently Asked Questions ...............................................................19 11.5 Revision History ..................................................................................21
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Transaction Instruction (TI) 1. TI Introduction
1.1 Background 1.1.1 Overview of HIPAA Legislation
HIPAA carries provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for translations, to enable health information to be exchanged electronically, and to adopt specifications for implementing each standard. HIPAA serves to: • Create better access to health insurance • Limit fraud and abuse • Reduce administrative costs
1.1.2 Compliance According to HIPAA The HIPAA regulations at 45 CFR 162.915 require that covered entities not enter into a trading partner agreement that would do any of the following: • Change the definition, data condition, or use of a data
element or segment in a standard • Add any data elements or segments to the maximum defined
data set • Use any code or data elements that are marked “not used” in
the standard’s implementation specifications or are not in the standard’s implementation specification(s)
• Change the meaning or intent of the standard’s implementation specification(s)
1.1.3 Compliance According to ASC X12 ASC X12 requirements include specific restrictions that prohibit trading partners from: • Modifying any defining, explanatory, or clarifying content
(Section 1), example (Sections 2 and 3), or appendix (Section 4) information contained in the implementation guide
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• Modifying any requirements: including loop, segment or element names, notes or rules, examples, appendix, or code list subsets from Section 2
1.2 Intended Use The Transaction Instruction component of this companion guide must be used in conjunction with an associated ASC X12 Implementation Guide. The instructions in this companion guide are not intended to be stand-alone requirements documents. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guides and is in conformance with ASC X12’s Fair Use and copyright statements.
All required segments within the 270 transactions must always be sent by the submitter and received by the payer. Optional information is sent when it is necessary for processing. Segments that are conditional are only sent when specific criteria are met.
Additionally, all required segments within the 271 transactions must always be sent back to the submitter by the payer.
1.3 References For full implementation guides and other 5010 standards – store.x12.org.
1.3.1 Included ASC X12 Implementation Guides This table lists the ASC X12N Implementation Guide for which specific transaction instructions apply and which are included in Section 3 of this document.
Unique ID Name 005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271)
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2. Getting Started This section contains payer-specific business rules and limitations for the 270/271 Eligibility Inquiry and Response transactions.
2.1 Working with the KMAP EDI Department This section describes how to interact with the Kansas Medical Assistance Program (KMAP) Electronic Data Interchange (EDI) department.
KMAP trading partners should exchange electronic health care transactions with KMAP through the secure website or through Interactive or Safe Harbor connections.
After establishing a transmission method and completing the required documentation, each trading partner must successfully complete testing. Additional information is provided in the next section of this companion guide. After successful completion of testing, production transactions may be exchanged.
2.2 Trading Partner Registration To register as a trading partner with KMAP, visit the EDI page of the public KMAP website to obtain and complete the EDI application.
Clearinghouses wishing to register as billing agent providers with KMAP must also download and complete the EDI application.
If there are questions regarding the EDI agreement, contact the EDI department at 1-800-933-6593, option 4, or [email protected].
2.3 Testing Overview All entities who wish to submit electronic transactions to KMAP in the HIPAA standard ASC X12 5010 format and receive any corresponding EDI responses must complete testing to ensure that their connections, systems, and software can and will produce data that is able to be processed by KMAP.
3. Testing with the Payer All submitters are required to successfully test their electronic transactions before submitting production files to KMAP. Testing instructions are sent after the EDI application is processed. They can also be found on the EDI page of the KMAP website for review before enrolling.
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4. Connectivity with the Payer 4.1 Process Flow 4.2 Transmission Administrative Procedures
Hewlett Packard Enterprise (HPE) supports several types of data transport depending upon the trading partner's needs. Providers and their representatives can submit and receive data through the KMAP website and value added networks (VANs) or switch vendors for interactive transactions.
KMAP website: Transaction files are uploaded and downloaded in the Trade Files menu on the secure website.
VANs or switch vendors typically support interactive transactions through a dedicated connection to the fiscal agent. This is a real-time connection that is restricted to only eligibility requests at this point.
Additional information to assist with EDI-related processes can be obtained from the KMAP website. The EDI department is available at 1-800-933-6593, option 4.
4.3 Retransmission Procedure When the system is unable to provide the status of a requested claim because of invalid or incomplete data on the incoming 270 transaction, a 271 transaction will be generated with the appropriate information. Refer to the Implementation Guide for further information. Upon receipt of this 271 transaction, the originating submitter can review the accompanying code to rectify or correct the original claim information and resubmit the request on a new 270 transaction.
4.4 Communication Protocol Specifications KMAP accepts 270 transactions through the following methods:
• Secure website
• Secure File Transfer Protocol (SFTP) for approved VANs
4.5 Passwords All submitters wanting to submit 270 transactions in batch to KMAP must have a presence in the secure website. Each provider, including the billing agent, are assigned a user name and password to access the system.
Those wanting to use an SFTP real-time connection must complete a separate enrollment process. For information on this process, contact the KMAP EDI department at 1-800-933-6593, option 4.
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5. Contact Information 5.1 EDI Customer Service
For all EDI-related inquiries, contact KMAP EDI Customer Service at: 1-800-933-6593, option 4 [email protected]
5.2 Provider Service Number For recipient eligibility information, claim status, billing and payment inquiries, and questions about the KMAP secure website, including Direct Data Entry (DDE) claims, contact KMAP Customer Service at 1-800-933-6593, option 8.
5.3 Relevant Websites KMAP
ASC X12 Store
Washington Publishing Company
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6. Control Segments/Envelope Definitions for 270/271 Transactions
6.1 ISA – Interchange Control Header Segment
270 Eligibility Verification Request Loop ID Reference Name Codes Notes/Comments N/A ISA ISA-Interchange Control
Header
N/A ISA05 Interchange ID Qualifier ZZ N/A ISA06 Interchange Sender ID Use the 9- or 10-digit code
assigned by KMAP. KMAP providers are assigned a 10-digit number. All other submitters will be assigned a 9-digit number.
N/A ISA07 Interchange ID Qualifier ZZ N/A ISA08 Interchange Receiver ID 00005 N/A ISA11 Repetition
Separator ^ This is the value that KMAP
will use in the 271 response.
N/A ISA15 Usage Indicator P N/A ISA16 Component
Element Separator : This is the value that KMAP
will use in the 271 response.
6.2 GS – Functional Group Header
270/271 Health Care Eligibility Request and Response Loop ID Reference Name Code/Value Notes/Comments N/A GS Functional Group Header N/A GS02 Application Sender's Code This will be equal
to the value in ISA06.
N/A GS03 Application Receiver's Code This will be equal to the value in ISA08.
6.3 ST – Transaction Set Header
270/271 Health Care Eligibility Request and Response Loop ID Reference Name Code/Value Notes/Comments N/A ST Transaction Set Header
N/A ST02 Transaction Set Control Number
Increment by 1 when multiple transaction sets are submitted.
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7. Payer Specific Business Rules and Limitations • Subscriber, Insured, and Member = Beneficiary in the KMAP
Environment KMAP does not allow for dependents to be enrolled under a primary subscriber; rather all enrollees/beneficiaries are primary subscribers within each program or managed care organization (MCO). If dependent level segments are received, they will be ignored during processing.
• KMAP Health Plan ID = KMAP Tax ID KMAP uses the KMAP tax ID in all instances requiring a health plan ID. At such a time as the National Health Plan ID is approved and available, that number will be used.
• Submitters Submissions by entities/individuals not on file with KMAP will be rejected.
• KMAP/HPE Provides a 999 Acknowledgment for All Batch Transactions Processed The acknowledgment will be received within 48 hours unless there are unforeseen technical difficulties. Responses to request transactions, such as a 270 or 276 request, are generated when the transaction is processed without errors. Responses for claim transactions processed without errors appear on the billing provider’s remittance advice. Note: The 835 and unsolicited 277 are only provided weekly.
• Employer Identification Numbers If the NM108 qualifier equals 24 or the REF01 qualifier equals EI within any loop, the corresponding value must be in the format of 999999999.
• Provider Identification KMAP will use the National Provider Identifier (NPI), where available, in all instances that require provider identification. In instances where a provider is exempt from requirements to use an NPI and an NPI is not available, the provider’s KMAP provider ID will be used.
• Responses (271s) from Inquiry (270s) For interactive inquiries, the average internal response time will be no longer than two seconds 90% of the time between 7:00 a.m. and 7:00 p.m. Central Standard Time, seven days a week. Additional delays due to networks outside of our control may be experienced. For batch inquiries, responses will be available within 48 hours of file submission. KMAP allows three possible combinations for eligibility verification searches. Beneficiary ID and Date of Service
o SSN and Date of Service Note: If the SSN is used, a date of birth is recommended but not required.
o Beneficiary First Name, Beneficiary Last Name, and Date of Birth
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• Methods of Batch Submission and Retrieval o Direct connection – Submitters with a leased line connection may
exchange interactive 270/271 transactions. o Internet – The KMAP website can be accessed for the exchange
of interactive eligibility requests and responses or for submission of batch 270 eligibility requests. A user ID and password issued by KMAP is required.
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8. Acknowledgements All 270 Claim Status Inquiry transactions submitted to the KMAP system will generate at least one acknowledgment and/or response.
8.1 Report Inventory • 999 Functional Acknowledgement The 999 acknowledgement is used to report the result of the compliance of the inbound transactions with the HIPAA standards, assuming the file itself is sent to the KMAP system in a readable format. The 999 will become available for retrieval within 24 hours of receipt of an uploaded batch file.
For real-time transactions, 999 Functional Acknowledgements will only be generated in cases where the originating transaction failed HIPAA compliance and the system was unable to produce a valid 271 transaction.
• 999 Functional Acknowledgement Trading partners submitting ASC X12 batch files through the KMAP CORE Safe Harbor connection will receive a 999 Functional Acknowledgement.
• TA1 Acknowledgment The TA1 Acknowledgement is generated when the submitted file contains errors in the Header-Trailer logic (ISA-IEA), causing the file itself to fail before it reaches the EDI system. When a TA1 Acknowledgement is generated, the system will not generate a 999 or a 271 response.
• 271 Health Care Eligibility Response Transaction The 271 Eligibility Response files are generated when a submitted 270 file completely passes the HIPAA compliance checks performed by the KMAP EDI system. Compliance for health care eligibility transactions are performed on a batch level. If any transaction within the batch fails compliance, the system considers the entire batch as a failed file and will not generate a 271 response.
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9. Trading Partner Agreements 9.1 Trading Partner
A trading partner is defined as any entity (provider, billing service, software vendor, clearinghouse, etc.) that has an agreement with the payer to transmit electronic data files to or receive electronic data files from KMAP.
For KMAP purposes, any provider that transmits their electronic files directly to the payer (such as through the secure website) can be considered their own trading partner.
To register as a trading partner with KMAP, an entity representative must complete the EDI agreement available for download from the EDI page of the KMAP public website and submit it appropriately.
The EDI agreement specifies which electronic transactions the submitter wishes to be able to submit and receive from KMAP.
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10. 270 Health Care Eligibility Inquiry – Transaction Specific
This section specifies ASC X12N 270 fields for which KMAP has specific requirements. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides.
Legend SHADED rows represent “segments” in the X12N implementation guide. NONSHADED rows represent “data elements” in the X12N implementation guide. “Loop – specific” comments should be indicated in the first segment of the loop.
10.1 270 Health Care Eligibility Benefit Inquiry
270 Eligibility Verification Request Loop ID Reference Name Codes Notes/Comments 2100A NM1 Information Source Name .
2100A NM103 Name Last or Organization Name
Use KANSAS MEDICAL ASSISTANCE PROGRAM.
2100A NM109 Identification Code 481124839 2100C NM1 Subscriber Name 2100C NM109 Identification Code Use the 11-digit Medicaid
beneficiary ID number assigned by KMAP.
10.2 271 Health Care Eligibility Response – Transaction Specific Information
This section specifies ASC X12N 271 fields for which KMAP has specific requirements.
271 Eligibility Verification Response Loop ID Reference Name Codes Notes/Comments 2100A NM1 Information Source Name 2100A NM109 Identification Code 481124839 2100A PER Information Source
Contact Information
2100A PER02 Name Kansas Medical Assistance Program Customer Service
2100A PER04 Communication Number 8009336593 2100A PER06 Communication Number 7852666112
Repeating Segments Begin Last Repetition: MMIS Assigned Trace Number 2000C TRN Subscriber Trace Number
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2000C TRN03 Originating Company Identifier
1486029925
Repeating Segment Ends Repeating Loop Begins
Loop 2110C: 1st Repetition (Medicare Part A) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB04 Insurance Type Code MA
2110C EB05 Plan Coverage Description
KMAP interprets the value MA as Medicare Part A
Loop 2110C: 2nd Repetition (Medicare Part B) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB04 Insurance Type Code MB
2110C EB05 Plan Coverage Description
KMAP interprets the value MB as Medicare Part B
Loop 2110C: 3rd Repetition (KAN Be Healthy Program) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB03 Service Type Code 81
2110C EB05 Plan Coverage Description
KMAP interprets the value 81 as KAN Be Healthy last screening date
Loop 2110C: 4th Repetition (Dental) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB03 Service Type Code 41
2110C EB05 Plan Coverage Description
KMAP interprets the value 41 as Last dental visit
Loop 2110C: 5th Repetition (KAN Be Healthy Eye Check) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB03 Service Type Code AN
2110C EB05 Plan Coverage Description
KMAP interprets the value AN as KAN Be Healthy – last eye exam
Loop 2110C: 6th Repetition (KAN BE Healthy Hearing Check) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB03 Service Type Code 71
2110C EB05 Plan Coverage Description
KMAP interprets the value 71 as KAN Be Healthy – last hearing test
Loop 2110C: 7th Repetition (Frames) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB03 Service Type Code AM
2110C EB05 Plan Coverage Description
KMAP interprets the value AM as Frames
Loop 2110C: 8th Repetition (Lenses)
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2110C EB Subscriber Eligibility or Benefit Information
2110C EB03 Service Type Code AO
2110C EB05 Plan Coverage Description
KMAP interprets the value AO as Lenses
Loop 2110C: 9th Repetition (Eye Exam) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB03 Service Type Code BR
2110C EB05 Plan Coverage Description
KMAP interprets the value BR as Eye exam
Loop 2110C: 10th Repetition (Eyeglasses) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB05 Plan Coverage Description
Eyeglasses
Loop 2110C: 11th Repetition (Eligibility) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB03 Service Type Code 30
2110C EB05 Plan Coverage Description
KMAP interprets the value 30 as Generic Eligibility
Loop 2110C: 12th Repetition (Managed Care) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB03 Service Type Code 1, 35, 56, MH
2110C EB05 Plan Coverage Description
KMAP interprets the values 1, 35, 56, and MH as Primary care provider
2110C EB Subscriber Eligibility or Benefit Information
2110C EB03 Service Type Code 30
2110C EB05 Plan Coverage Description
KMAP interprets the value 30 as Managed care organization
Loop 2110C: 14th Repetition (Lock-in) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB05 Plan Coverage Description
Lock-in
Loop 2110C: 15TH 2110C: 15th Repetition (Third-Party Liability) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB03 Service Type Code 30
2110C EB05 Plan Coverage Description
KMAP interprets the value 30 as Third Party Liability
Loop 2110C: 16th Repetition (Therapeutic Days Used) 2110C EB Subscriber Eligibility or
Benefit Information
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2110C EB05 Plan Coverage Description
Therapeutic days used
Loop 2110C: 17th Repetition (Patient Liability Amount) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB05 Plan Coverage Description
Patient liability amount
Loop 2110C: 18th Repetition (Psychological Testing) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB05 Plan Coverage Description
Psychological testing
Loop 2110C: 19th Repetition (Psychotherapy) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB05 Plan Coverage Description
Psychotherapy
Loop 2110C: 20th Repetition (Spenddown) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB05 Plan Coverage Description
KMAP interprets the value Y as Spenddown
Loop 2110C: 21st Repetition (Level 2 Transportation) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB05 Plan Coverage Description
LEVEL 2 – Nonambulatory
Loop 2110C: 22nd Repetition (Level 1 Transportation) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB05 Plan Coverage Description
LEVEL 1 – Ambulatory
Loop 2110C: 22nd Repetition (Health Homes) 2110C EB Subscriber Eligibility or
Benefit Information
2110C EB05 Plan Coverage Description
Health Home
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11. Appendix 11.1 Implementation Checklist
11.2 Business Scenarios This appendix contains typical business scenarios of 270 inquiries. The actual data streams linked to these scenarios are included in the Transmission Examples section.
KMAP allows three possible combinations for eligibility verification searches. • Beneficiary ID and Date of Service • SSN and Date of Service
Note: If the SSN is used, a date of birth is recommended but not required.
• Beneficiary First Name, Beneficiary Last Name, and Date of Birth
11.3 Transmission Examples
11.4 Frequently Asked Questions This appendix contains a compilation of questions and answers relative to KMAP and its providers. A typical question would involve a discussion about code sets and their effective dates.
Q: Who do I contact for support if a problem arises? What are the hours?
A: Contact the EDI Helpdesk by email or at 1-800-933-6593, option 4, Monday through Friday, from 8 a.m. to 7 p.m. CST.
Q: What CORE-required service codes are supported?
A: Reference the following table: Service Type Code Description
1 Medical Care 2 Surgical 4 Diagnostic X-Ray 5 Diagnostic Lab 6 Radiation Therapy 7 Anesthesia 8 Surgical Assistance
12 Durable Medical Equipment Purchase 13 Ambulatory Service Center Facility 18 Durable Medical Equipment Rental 20 Second Surgical Opinion
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33 Chiropractic 35 Dental Care 40 Oral Surgery 42 Home Health Care 45 Hospice 47 Hospital 48 Hospital - Inpatient 50 Hospital - Outpatient 51 Hospital - Emergency Accident 52 Hospital - Emergency Medical 53 Hospital - Ambulatory Surgical 62 MRI/CAT Scan 65 Newborn Care 68 Well Baby Care 73 Diagnostic Medical 76 Dialysis 78 Chemotherapy 80 Immunizations 81 Routine Physical 82 Family Planning 86 Emergency Services 88 Pharmacy 93 Podiatry 98 Professional (Physician) Visit - Office 99 Professional (Physician) Visit - Inpatient A0 Professional (Physician) Visit - Outpatient A3 Professional (Physician) Visit - Home A6 Psychotherapy A7 Psychiatric - Inpatient A8 Psychiatric - Outpatient AD Occupational Therapy AE Physical Medicine AF Speech Therapy AG Skilled Nursing Care AI Substance Abuse AL Vision (Optometry) BG Cardiac Rehabilitation BH Pediatric MH Mental Health UC Urgent Care
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11.5 Revision History Document
Version Number Change Date Change Page
Numbers Reason for Change
Version 1.0 June 18, 2010 Creation of manual. Version 2.0 May 26, 2011 Entire manual
Errata version. Updated EB03 field elements for loop 2110C repetition 5, 6, and 12.
Version 2.1 August 1, 2011 21 Updated acceptable format for EI number.
Version 3.0 October 24, 2014 Entire manual CAQH CORE. Version 4.0 September 23, 2015 Entire manual ASC X12 review.
HPE updates. Version 5.0 June 21, 2016 7, 9, 19 HPE email updates.
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