Gary BeattyPresidentWashington Publishing Company

ChairX12N Insurance Subcommittee

Introduction to 270/271

Health Care EligibilityInquiry/Response

August 20, 2001

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

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

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

270/271 Eligibility Inquiry/Response

Background

General Simple Inquiries

Specific Requests: Complex Inquiries

EligibilityRequest/Response

Complexity

270/271 Eligibility Inquiry/Response

UnsupportedBusiness Functions

•Authorization requests

•Certification requirements

•Utilization management/review requirements

278Health Care Services Review

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

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~

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

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…

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?

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~

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?

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

The Comparison

X12N

XML

Size : 1k

Size : 3k

X12 XMLCurrent Excerpt from 270 Implementation Guide

270 Implementation Guide Excerpt with X12 XML

NM1*IL*1*Brown*Jane****MI*345678901~

X12 XML Current Excerpt from 270 Implementation Guide

270 Implementation Guide Excerpt with X12 XML

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:

gary@wpc-edi.com