1 Copyright 2019, UCare, All Rights Reserved. UCare® is a registered service mark of UCare Minnesota and UCare Health, Inc. HIPAA Transaction Standard Companion Guide 270/271 Health Care Eligibility Benefit Inquiry and Response VERSION: 1.8 DATE: 06/25/2019
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HIPAA Transaction Standard Companion Guide …...2018/04/09 · 270/271 transaction set in the electronic data interchange (EDI) environment. The 270 transaction is used to request
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1 Copyright 2019, UCare, All Rights Reserved. UCare® is a registered service mark of UCare Minnesota and UCare Health, Inc.
HIPAA Transaction Standard Companion Guide 270/271 Health Care Eligibility Benefit
2 Copyright 2019, UCare, All Rights Reserved. UCare® is a registered service mark of UCare Minnesota and UCare Health, Inc.
Disclosure Statement This document is intended to be a companion guide for use in conjunction with the ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides. This document contains clarifications as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Standard for Electronic Transactions. This document is not intended to convey information that exceeds the requirements or usages of data expressed in the ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides defined by HIPAA. UCare is committed to maintaining the integrity and security of health care data in accordance with applicable laws and regulations. This material contains confidential, propriety information. Unauthorized use or disclosure of the information is strictly prohibited. The information in the document is furnished for UCare and Trading Partner use only. Changes are periodically made to the information in this document, these changes in the product and/or program described in the publication at any time. Disclosure of beneficiary eligibility data is restricted under the provisions of the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Provider Beneficiary eligibility transaction is to be used for conducting UCare business only. Please note: The 271 response returned by the 270/271 application should not be interpreted as a guarantee of payment. Payment of benefits remains subject to all health benefit plan terms, limits, conditions, exclusions and the member’s eligibility at the time services are rendered.
12 Copyright 2019, UCare, All Rights Reserved. UCare® is a registered service mark of UCare Minnesota and UCare Health, Inc.
Chapter 6: Payer-Specific Business Rules and Limitations
This section describes UCare specific rules and limitations associated with the 270/271 transaction. It is important to review these as they may differ from rules and limitations required by other payers. UCare’s trading partners must adhere to the following business rules and limitations for submitting transactions in real time:
Only one transaction should be submitted per functional group.
Only one functional group should be submitted per interchange.
Member data should always be sent in the Subscriber Loop of the transaction (21xxC loops); UCare will not accept Dependent Loops (21xx D loops).
Search criteria used to identify a member includes: o Member ID, Date of Birth, and Last Name.
UCare strongly recommends always sending the member ID located on the member’s ID card. o If member ID is used: member ID and either last name or DOB are required.
o If member ID is not used: last name and DOB are required.
If no date of service is received, the current date will be considered as the date of service
When sending a 270 inquiry, using a specific Service Type Code related to the services being performed will provide
a more streamlined response. Service Type Codes that are not explicitly supported by UCare will return a response
equivalent to the Service Type Code 30 – Health Benefit Plan Coverage.
1-Medical Care 86-Emergency Services UC-Urgent Care
33-Chiropractic 88-Pharmacy
35-Dental Care 98-Professional (Physician) Visit-Office
47-Hospital AL-Vision (Optometry)
48-Hospital Inpatient MH-Mental Health
50-Hospital Outpatient
Future dates are supported and can be reported up to the last day of the current month.
Dates of service in the past are supported 12 months prior to the current date.
Procedure and/or diagnosis codes are not used to determine benefits.
Entities subject to Minnesota Statutes, section 62J.536 and related rules must follow the data content and other transaction specific information of the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X279A1 Health Care Eligibility Inquiry and Response (270/271). A copy of the Minnesota Uniform Companion Guide is available from the Minnesota Department of Health at no charge at: http://www.health.state.mn.us/asa/rules.html.
15 Copyright 2019, UCare, All Rights Reserved. UCare® is a registered service mark of UCare Minnesota and UCare Health, Inc.
Chapter 9: Transaction Specific Information
A Transaction Loop is a group of related segments. UCare specific values are required for the elements that comprise the segments for the 270/271 Transaction Loops. The following section identifies these loops, their segments and their required element values. [Note: UCare does not support Dependent Loops: 2100D, 2110D, 2115D, and 2120D.] 270
Loop 2100A (270) Information Source
Loop Segment Element Name Code Definition / Notes
2100A NM1 NM101 Entity Identifier Code ‘PR’ Payer
2100A NM1 NM102 Entity Type Qualifier ‘2’ 2: Non-Person Entity
2100A NM1 NM103 Organization Name ‘UCARE’ Health Plan Name
2100C DTP DTP02 Date/Time Period Format Qualifier ‘D8’
‘RD8’
D8: Date expressed in format CCYYMMDD; RD8: Range of Dates expressed in format CCYYMMDD-CCYYMMDD
2100C DTP DTP03 Date Time Period Range of dates is acceptable, but UCare only uses first date in range. If date is not provided, UCare will use current date.
Loop 2110C (270) Subscriber Eligibility & Benefit Information
Loop Segment Element Name Code Definition / Notes
2110C EQ UCare supports only one occurrence of the EQ segment per transaction
2100B NM1 NM109 Identification Code Information on 270 transaction sent back on 271 transaction
Loop 2100C (271) Subscriber Information
Loop Segment Element Name Code Definition / Notes
2100C REF REF01 Group Number ‘6P’ Group Number
2100C REF REF02 Plan Number ‘18’ Plan Number
2100C DMG DMG02 Date of Birth Format CCYYMMDD
2100C DMG DMG03 Gender Code Gender Code
2100C N3 N301 Address Information Subscribers Address
2110C N3 N302 Address Information Use this information for the second line of the address information
2100C N4 N401 City Name Subscriber City Name
2100C N4 N402 State Subscriber State Code
2100C N4 N403 Postal Code Subscriber Postal Zone or ZIP Code
Loop 2110C (271) Subscriber Eligibility or Benefit Information
Loop Segment Element Name Code Definition / Notes
2110C EB EB01 Eligibility or Benefit Information
1 5 A B C F G I
1: Active Coverage 5: Active – Pending Investigation A: Co-Insurance B: Co-Payment C: Deductible F: Limitations G: Out of Pocket (Stop Loss) I: Non-Covered
2110C EB EB03 Service Type Code Explicit Service Type Code Response if requested
2110C EB EB05 Plan Coverage Description Plan Description, sent with Service Type Code ‘30’
2110C EB EB07 Monetary Amount Qualifier based on EB01. EB01=A, B, C, G
2110C DTP DTP01 Date/Time Qualifier ‘356’ ‘357’
356: Eligibility Begin Date 357: Eligibility End Date
2110C DTP DTP03 Date/Time Period Dates associated with DTP01 qualifier
2110C MSG MSG01 Free-Form Message Text Additional information as required
2110C MSG MSG02 Free-Form Message Text Additional information as required
The transaction-specific information for entities subject to Minnesota Statutes, section 62J.536 and related rules is incorporated by reference from the Minnesota Uniform Companion Guide (MUCG) for the ASCX12/005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) Version 6.0, at: http://www.health.state.mn.us/asa/rules.html. Readers are referred to the MUCG for information and instructions to comply with Minnesota’s requirements.