Gary Beatty Introduction to - ehcca.com
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Gary Beatty President Washington Publishing Company Chair X12N Insurance Subcommittee Introduction to 270/271 Health Care Eligibility Inquiry/Response August 20, 2001
Transcript of Gary Beatty Introduction to - ehcca.com
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.
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