Eligibility Web Service Companion Guide

Transcription

1 Eligibility Web Service Companion Guide 2010 Gateway EDI, LLC. Last Updated: 10/30-/2014 5:40:00 PM Confi de nti al An d Propri e t ar y: This document, or any information contained herein, may not be duplicated, published, or disclosed by any means without prior permission of Gateway EDI, LLC.

2 Web Services Revision History Date Revision Author 1/1/ Initial Version 1/22/ Updated template Malvin Ly 2/25/ Updated payer specific fields Malvin Ly 4/19/ Updated date format, removed century. Malvin Ly 10/25/ Removed payer specific information. Malvin Ly 12/28/ Removed SSN requirement Malvin Ly 9/23/ Removed subscriber ID and provider ID requirements 12/12/ Added Provider Name as required field and removed Dependent Relationship Code from required fields 1/23/ Removed gender, date of birth and name from required fields, as applicable Malvin Ly Danielle Montgomery Danielle Montgomery 10/30/ Added HCPCS Code Shikha Chauhan Confi de nti al An d Propri e t ar y: This document, or any information contained herein, may not be duplicated, published, or disclosed by any means without prior permission of Gateway EDI, Inc. 2

3 Table of Contents 1. INTRODUCTION PURPOSE OF THIS GUIDE DESCRIPTION RESTRICTIONS PARAMETERS LIST OF REQUIRED ELIGIBILITY PARAMETERS Information Source Details Information Receiver Details Subscriber Details Dependent Details ADDITIONAL INFORMATION DOCUMENTATION...7 Confi de nti al An d Propri e t ar y: This document, or any information contained herein, may not be duplicated, published, or disclosed by any means without prior permission of Gateway EDI, Inc. 3

4 1. Introduction 1.1. Purpose of this guide The intent of this technical reference document is to provide a place to capture technical details about the Gateway EDI payer list web service. This manual provides an overview for different programming interfaces and classes that allow IT staff and programmers, who are developing external clients, to connect to Gateway EDI The Gateway EDI eligibility web service allows providers with registered with Gateway EDI to make realtime eligibility transactions from their practice management system, bypassing the need to log into the Gateway EDI website Restrictions For real-time transactions, it is required that the 270 transaction contain only one patient request. One patient is defined as either one subscriber loop if the member is the patient or one dependent loop if the dependent is the patient.

5 2.1. List of Required Eligibility Parameters This list of parameters are required fields for all eligibility transactions send to the Gateway EDI eligibility web service, except as otherwise noted Information Source Details: 1 GediPayerID The GEDI specific payer identifier Information Receiver Details: 1 ProviderFirstName Provider First Name Required when individual provider name is sent in the inquiry 2 ProviderLastName Provider Last Name/Organization Name 3 NPI National Provider Identifier Subscriber Details: 1 InsuredFirstName Subscriber First Name subscriber or if the Payer requires this information to identify the patient. 2 InsuredLastName Subscriber Last Name subscriber or if the Payer requires this information to identify the patient. 3 InsuranceNum Required when the payer needs this information to identify patient. 4 InsuredDob Subscriber Date of birth (YYYYMMDD) subscriber.

6 5 InsuredGender Subscriber Gender subscriber. 6 Insured HCPCS Codes Health Care Financing Administration Common Procedural Coding System Codes subscriber and provider believes payer supports this functionality and Service Type Codes is not passed in the request Dependent Details: 1 DependentFirstName Dependent First Name 2 DependentLastName Dependent Last Name 3 DependentDob Dependent Date of birth (YYYYMMDD) 4 DependentGender Dependent Gender 5 Dependent HCPCS Codes Health Care Financing Administration Common Procedural Coding System Codes dependent and provider believes payer supports this functionality and Service Type Codes is not passed in the request.

7 3.1. Documentation EligibilityWebServiceSample.zip Realtime Eligibility Webservice Vendor Toolkit.pdf Payer Specific Data Elements 2010.pdf