UPMC HEALTH PLAN. HIPAA EDI Companion Guide

Transcription

1 UPMC HEALTH PLAN HIPAA EDI Companion Guide For 270/271 Eligibility Inquiry & Response Companion Guide Version: 1.2 Refers to the Implementation Guide Based on X12 Version X279A1 ~ 1 ~

2 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. The information in this document is provided for UPMC Health Plan and its associated Trading Partners. 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. This document is not intended, and should not be regarded, as a substitute for the ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides. UPMC Health Plan may make improvements and/or changes to the information contained in this document without notice. This document may be copied and distributed without direct permission from the author. Preface This companion guide (CG) is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. This companion guide to the ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides adopted under HIPAA will clarify and specify UPMC Health Plan communication protocols, business rules and information applicable to the 270/271 Eligibility Inquiry & Response transaction. Transmissions based on this companion guide, used in tandem with the X12N Implementation Guides, are compliant with X12 syntax, those guides, and HIPAA. ~ 2 ~

3 Overview The 270 and 271 Transactions are used in conjunction with one another: the 270 Transaction is used to inquire about the eligibility benefit status of a patient, and the 271 Transaction is returned in response to that inquiry. The information in this overview details the UPMC Health Plan guidelines relevant to the implementation of 270 and 271 Transactions for Users of this guide will need to have a thorough understanding of, and experience with, the following: The ANSI ASC X12 Implementation Guides HTTPS and CORE II compliant SOAP Provider Eligibility UPMC Health Plan is using the CAQH CORE Phase II Connectivity standards, and will work with submitters who also have the ability to utilize CORE or can connect via a Core Phase II certified clearinghouse. Currently, UPMC Health Plan supports SOAP which is 1 of 2 CORE compliant envelope standards: SOAP + WSDL: supported HTTP MIME Multipart: may be supported in the future. UPMC Health Plan also only supports CORE Real Time transactions. Batch transactions may be supported in the future. For more information regarding CORE, please visit System Availability Inquiries may be submitted 24 hours a day, seven days a week. If we are performing maintenance, you will receive a response indicating we are unable to respond at this time. Contact Information UPMC Health Plan EDI/Issue Reporting [email protected] Provider OnLine Web: Help Line: ~ 3 ~

4 Provider Services Telephone Provider Services should be contacted at if you have questions regarding the details of a member s benefits. Provider Services is available Monday Friday 7 a.m. to 7 p.m. Eastern Standard Time. ~ 4 ~

5 CORE Phase II Compliant Test/Production URLs Listed here are the CORE SOAP Web Service URL addresses required to connect with the UPMC Health Plan. Test SOAP: Test WSDL: Prod SOAP: Prod WSDL: CORE Phase II Specific System/Error Messages: The following are the different message responses and error notifications that may be received when submitting CORE compliant requests. HTTP 200 OK: Returned when authorization is passed and interface is successful with the real time production system. A response with X12 data content will be returned. HTTP 500 Internal Server Error: If the username and/or password included in the request are not valid an HTTP 500 Internal Server error response with no data will be returned like this. HTTP/ Internal Server Error Content-Length: 418 Content-Type: application/soap+xml; charset=utf-8 Server: Microsoft-IIS/7.0 X-Powered-By: ASP.NET Date: Wed, 10 Oct :35:00 GMT <s:envelope xmlns:s=" <s:body> <s:fault> <s:code> <s:value>s:sender</s:value> </s:code> <s:reason> <s:text xml:lang="en-us">system.servicemodel.faultexception: The Username/Password could not be verified. at UPMCHP.COREIISoapRealtimeAndBatch.CoreSoapService.CustomUserNameValidator.Validate( String username, String password)</s:text> </s:reason> ~ 5 ~

6 </s:fault> </s:body> </s:envelope> Server Errors: When the real time production system is not able to process a real-time request due to interface failures or other system unavailability a standard 5xx series error such as HTTP 500 Internal Server Error or HTTP 503 Service will be returned by the application. In this scenario, the submitter will need to resubmit the request once the error has been resolved. Other Error Messages: Depending on the error location, there are two other ways error messages may be returned to the sender. 1. Errors that occur within the business messages are returned in the standard CORE SOAP message format with the ErrorCode and ErrorMessage metadata values set to reflect the specific error. 2. Invalid Username or Password, like the one in the HTTP 500 error above, and other unknown error messages may be returned in a CustomFault SOAP message format. ~ 6 ~

7 270 ISA Data Requirements Sender/Receiver Values ISA05 = ZZ ISA06 = Trading Partner determined Unique Identifier ISA07 = 33 ISA08 = ISA12 = GS02 = Trading Partner determined Unique Identifier GS03 = GS08 = X279A1 NOTE: The Sender ID Qualifier, Sender ID, Receiver ID Qualifier, and Receiver ID are configurable and can be set to any mutually agreed upon value prior to initiating testing. Member Matching Criteria The two scenarios where we can accurately report member information are when we receive all of the unique member identifiers detailed below. Scenario 1: Member Identification Number Member First and Last Name Member Date of Birth Scenario 2: Member Exact First and Last Name Member Date of Birth Notes: No dependent level data (NM1*03) should be sent within a 270 Eligibility Inquiry file. All UPMC Health Plan members can be uniquely identified by Member ID number. The Dates of Service must also be included so that it can be determined whether the services fall within a valid eligibility span. ~ 7 ~

8 Sample 270 Transaction Scenario The below scenario maps the provided sample payer, patient, and provider information into the proceeding sample 270 File. Payer (Information Receiver) Provider (Information Source) Service Information UPMC Health Plan William J. Line, MD Service Provider Number: Communication Contact Name: W. Line Phone Number FAX Service Date: 04/08/2011 Billing Date: 04/09/2011 Patient Clark Kent - Subscriber Member Identification Number Group or Policy Number DOB 07/04/1977 Example 270 Data String The following transmission sample illustrates the file format used for an EDI transaction, which includes delimiters and data segment symbols. The sample includes the ISA (Interchange Control) and GS (Functional Group) portions of a transmission, and only one ST/SE segment. This sample contains a line break after each tilde to provide an easy illustration of where a new data segment begins. ISA*00* *00* *ZZ*TPUniqueID *33*95216 *110311*1136*^*00501* *0*P*:~ GS*HS* TPUNIQUEID *95216* *1136* *005010X279A1~ ST*270*0001*005010X279A1~ BHT*0022*13* * *1136~ HL*1**20*1~ NM1*PR*2*UPMC HEALTH PLAN*****PI* ~ HL*2*1*21*1~ NM1*1P*1*LINE*WILLIAM*J***XX* ~ HL*3*2*22*0~ TRN*1*K ~ NM1*IL*1*KENT*CLARK*S***MI* ~ REF*SY* ~ DMG*D8* *M~ DTP*472*RD8* ~ EQ*30~ SE*14*0001~ GE*1* ~ IEA*1* ~ ~ 8 ~

9 271 ISA Data requirements Sender/Receiver Values ISA05 = 33 ISA06 = ISA07 = ZZ ISA08 = Trading Partner determined Unique Identifier ISA12 = GS02 = GS03 = Trading Partner determined Unique Identifier GS08 = X279A1 NOTE: The Sender ID Qualifier, Sender ID, Receiver ID Qualifier, and Receiver ID are configurable and can be set to any mutually agreed upon value prior to initiating testing. Sample 271 Transaction Scenario The below scenario maps the provided sample payer, patient, and provider information into the proceeding sample 271 File. Payer (Information Source) Provider (Information Receiver) Service Information Patient UPMC Health Plan William J. Line, MD Service Provider Number: Communication Contact Name: W. Line Phone Number FAX Service Date: 04/08/2011 Billing Date: 04/09/2011 Clark Kent - Subscriber Member Identification Number Group or Policy Number SSN DOB 07/04/1977 ~ 9 ~

10 Example 271 Data String The following transmission sample illustrates the file format used for an EDI transaction, which includes delimiters and data segment symbols. The sample includes the ISA (Interchange Control) and GS (Functional Group) portions of a transmission, and only one ST/SE segment. This sample contains a line break after each tilde to provide an easy illustration of where a new data segment begins. ISA*00* *00* *33*95216 *ZZ*TPUniqueID *110409*1547*^*00501* *0*P*:~ GS*HB*95216*UPMCELIG* *154732*100*X~ ST*271*100001*005010X279A1~ BHT*0022*13*PATMGMT # * *1547~ HL*1**20~ NM1*PR*2*UPMC HEALTH PLAN*****NI*95216~ PER*IC*UPMC HEALTH PLAN MEMBER SERVICES*TE* ~ HL*2*1*21*1~ NM1*1P*1*LINE*WILLIAM*J***XX* ~ REF*HPI* ~ HL*3*2*22*0~ TRN*2*EDI_CONTROL_ * * ~ TRN*2*RE * * ~ NM1*IL*1*KENT*CLARK*S***MI* ~ REF*SY* ~ PER*IC*CLARK KENT~ DMG*D8* *M~ DTP*472*D8* ~ DTP*356*D8* ~ EB*1*FAM*98*HM*13H-HVHS PREFERRED PLAN******U*U~ EB*1*FAM*99*HM*13H-HVHS PREFERRED PLAN******U*U~ EB*1*FAM*30*HM*13H-HVHS PREFERRED PLAN******U*U~ EB*B*FAM*AC*HM*O/P CD - Extended*32*25****U*U~ EB*B*FAM*AC*HM*O/P CD - Full*32*25****U*U~ EB*B*FAM*AC*HM*O/P CD - Half*32*25****U*U~ EB*B*FAM*33*HM*Chiro Exm/Manip Under 13 Yearly Quantity 25*22*25**VS*25*U*U~ EB*B*FAM*33*HM*Chiro exam/manipulations Yearly Quantity 25*22*25**VS*25*U*U~ EB*B*FAM*51*HM*ER Facility -autopay*32*50****u*u~ EB*B*FAM*52*HM*ER Facility-NonAutopay*32*50****U*U~ EB*B*FAM*9*HM*Home Infusion Thrp CM/MC Daily Quantity 1*7*0**VS*1*U*U~ EB*B*FAM*A8*HM*O/P MH -ACT 150-EXTENDED*32*25****U*U~ EB*B*FAM*A8*HM*O/P MH - ACT Full*32*25****U*U~ EB*B*FAM*A8*HM*O/P MH - ACT Half*32*25****U*U~ EB*B*FAM*A8*HM*O/P MH - Extended*32*25****U*U~ EB*B*FAM*A8*HM*O/P MH - Full*32*25****U*U~ EB*B*FAM*A8*HM*O/P MH - Half*32*25****U*U~ EB*B*FAM*93*HM*Rtn Foot Care Med Nec Dx*32*25****U*U~ EB*B*FAM*9*HM*Specialist Off/Outpt Vst*32*25****U*U~ EB*B*FAM*AD*HM*PT/OT/ST Yearly Quantity 60*22*15**VS*60*U*U~ EB*B*FAM*98*HM*PCP Office Visit-BH Prov*32*15****U*U~ EB*B*FAM*98*HM*Pain Management-HVHS*32*25****U*U~ EB*B*FAM*93*HM*Podiatrist*32*25****U*U~ ~ 10 ~

11 EB*B*FAM*98*HM*PCP Physician visit*32*15****u*u~ EB*B*FAM*A8*HM*Psych Test BH Diag*32*25****U*U~ EB*B*FAM*A8*HM*Psych Test Med Diag*32*25****U*U~ EB*B*FAM*BF*HM*Pulmonary Rehab Yearly Quantity 24*22*15**VS*24*U*U~ EB*B*FAM*AG*HM*213D ELIG EXPENSES (HRA)*32*0****U*U~ EB*B*FAM*98*HM*Vision Exam Med Nec*32*25****U*U~ EB*L****PRIMARY CARE PHYSICIAN~ LS*2120~ NM1*P3*1*PRIMARY CARE DOCTOR*****SV*579F~ N3*918 THIRD AVENUE~ N4*BEAVER FALLS*PA*15010~ PER*IC* ~ LE*2120~ EB*C*IND*30**IND Deductible Amount*27*500*****N~ EB*C*IND*30**IND Deductible Amount Applied*24*0*****N~ EB*C*IND*30**IND Deductible Amount Remaining*29*500*****N~ EB*C*FAM*30**FAM Deductible Amount*27*1000*****N~ EB*C*FAM*30**FAM Deductible Amount Applied*24*0*****N~ EB*C*FAM*30**FAM Deductible Amount Remaining*29*1000*****N~ EB*G*IND*30**IND OOP Amount*27*10000*****N~ EB*G*IND*30**IND OOP Amount Applied*24*0*****N~ EB*G*IND*30**IND OOP Amount Remaining*29*10000*****N~ EB*G*FAM*30**FAM OOP Amount*27*20000*****N~ EB*G*FAM*30**FAM OOP Amount Applied*24*0*****N~ EB*G*FAM*30**FAM OOP Amount Remaining*29*20000*****N~ EB*F*IND*30**Lifetime Amount*32* ~ EB*F*IND*30**Lifetime Amount Remaining*33* ~ GE*1*100~ IEA*1* ~ ~ 11 ~