Health Identification Card Standard Version 1.2

Transcription

1 UHIN Health Identificatin Card Standard Apprved Health Identificatin Card Standard Versin 1.2 UHIN Health Identificatin Card Standard is cmpatible with natinal implementatin guides fr health identificatin cards. Purpse The Health Identificatin Card Standard has been created t standardize the patient health identificatin card infrmatin. This identificatin card addresses the human-readable appearance and machine-readable infrmatin used by the healthcare industry t btain eligibility and/r benefit infrmatin. The Health Identificatin Card prvides identificatin infrmatin nly. It des nt cnvey diagnstic, prescriptive, medical encunter, bi-security, nn-identifying demgraphic r ther data abut the cardhlder. Applicability Payers (issuers), Subscribers and Prviders f healthcare ding business in the state f Utah. Basic Cncepts A card issuer issues a health identificatin card t a cardhlder(s). The cardhlder(s) shares their health identificatin card fr identificatin purpses with apprpriate card users. Example usage f a health identificatin card in a prvider ffice: Patient presents health identificatin card t prvider. A health identificatin card is the means by which a patient cnveys insurance identificatin t the prvider. Once the prvider has btained the insurance identificatin, the prvider is in psitin t generate standard transactins such as eligibility inquiry, precertificatin, claims, and claims attachments. Transactins such as the eligibility inquiry may be autmatically generated if the health identificatin card has machine readable infrmatin that is captured by the prvider system which is prgrammed t create a 270 transactin. The use f a health identificatin card fr creating an autmated eligibility request is expected t: reduce phne calls t the payer and encurage adptin f the 270 Eligibility Inquiry Respnse transactin. Detail See Sectins 1 thrugh 4 and Appendices A thrugh D fr detailed infrmatin. This standard adpts the mst current, apprved versin f the WEDI Health Identificatin Card Implementatin Guide. The Guide can be btained at the fllwing website: The symblgy technlgy t be used in this standard is the PDF417. Inclusin f the Data Matrix r ther symblgy technlgy is ptinal. Page 1 f 15

2 UHIN Health Identificatin Card Standard Apprved Basic Definitins Card Issuer/Payer - Organizatin that issues health identificatin cards. In this dcument we are referring t the payer. Cardhlder/Subscriber - Individual, family, r rganizatin t which a health identificatin card is issued t. Health Identificatin Card - Card used t identify the card issuer and the cardhlder t facilitate health care transactins and t prvide input data fr such transactins. State Regulated refers t thse payers that are under the auspice f the Utah State Department f Insurance. Implementatin Issues Card Issuer: Issuers will need t mdify their printed health identificatin card t align with this Standard. Current card prductin vendrs can prduce the health identificatin cards. Payers will need t determine a rll ut printing and distributin plan fr the standardized cards Payers need t be able t have the ability t accept a 270 and respnd with a rbust 271 transactin. See Eligibility Inquiry and Respnse Standard. Card User: The prvider cmmunity will need t be educated n hw t read the infrmatin prvided n the Health Identificatin card Prviders will need t knw hw the infrmatin cntained n the card can be used t create electrnic transactins. Prviders will need t btain and install hardware that can read and prcess the card technlgy (see Sectin 3) n the health identificatin ID card in rder t autmate electrnic transactins. Prviders will need t update their sftware r purchase sftware that will interface with the hardware t read the infrmatin n the card and create standard electrnic transactins (e.g. 270). It is recmmended that prviders develp the ability t generate a 270 (Eligibility Request) transactin autmatically and t receive the 271 (Eligibility Respnse) frm the infrmatin surce. Recmmendatins: The Health Identificatin Card Standard addresses payer identificatin cards (medical), in the future there may be ther identificatin card(s) (i.e. RHIO, prviders, pharmacy, cmbinatin cards, etc) which will be addressed when the need is identified. Pharmacy and/r cmbinatin (medical/pharmacy) health identificatin card guidance has been included in Appendix A fr thse trading partners wh wish t issue these kinds f cards. Payers are strngly encuraged t develp a fast batch eligibility transactin in rder t supprt the use f the eligibility transactin. Histry: (MM/DD/YY) Original A* 1 A 2 A3 A 4 ORIGINATION DATE 10/25/ /28/10 05/19/11 APPROVAL DATE 05/02/ /03/10 05/30/2012 EFFECTIVE DATE 06/02/ /03/10 06/30/2012 * A = Amendment Page 2 f 15

3 UHIN Health Identificatin Card Standard Apprved UHIN Health Identificatin Card Standard Cntents Sectin 1 Health Identificatin Card Elements... 4 Sectin 2 Essential Infrmatin and Design Cmmn t the Health Identificatin Card Cnventins Cardhlder Name Placement f Essential Infrmatin... 6 Sectin 3 Data Structure fr Machine-Readable Infrmatin Standard Data Structure Discretinary data lp Example f Machine-Readable Data Health Identificatin Card t X Healthcare Eligibility Benefit Inquiry Mapping Sectin 4 Sample Health Identificatin Cards Appendix A Pharmacy and/r Cmbinatin Identificatin Card Guidance Appendix B Basic Health Identificatin Card Definitins Appendix C Health Identificatin Card t X Healthcare Eligibility Benefit Inquiry Mapping Page 3 f 15

4 UHIN Health Identificatin Card Standard Apprved Sectin 1 Health Identificatin Card Elements 1 (Please reference Appendix B fr basic definitins) Infrmatin Element Standard Label Usage Lcatin Card issuer name N/A Mandatry Frnt (Tp left) Card issuer lg N/A Optinal Frnt (Tp next t card issuer name) Plan Name N/A Mandatry Frnt Plan Regulated by State State Regulated Mandatry Frnt/Back Netwrk Affiliatin N/A Required when Frnt/Back cntracted Netwrk lg N/A Required when cntracted Frnt (next t the netwrk name). Emplyer Name N/A Required when Frnt cntracted Emplyer Lg N/A Required when Frnt (next t the Administrative Services Only (ASO) r Third Party administratr (TPA) Name Administrative Services Only (ASO) r Third Party administratr (TPA) Lg N/A N/A cntracted Required when cntracted Required when cntracted emplyer name) Either Side Recmmend t place n the back side Either Side (next t the ASO r TPA) Card issuer identifier Issuer (80840) Reserved fr Future Frnt Side Use Cardhlder ID ID Mandatry Frnt Cardhlder first name, middle initial, cardhlder last name A suitable label identifying this value r left blank Mandatry (Name) Optinal (Label) Frnt Dependents N/A Optinal Frnt Medical C-Pay Office C-Pay Mandatry Frnt Specialty C-Pay Specialty C-Pay Mandatry Frnt Yearly Deductible Deductible Mandatry Frnt Claims submissin name(s) and address(es) Telephne number(s) and name(s) Web address A suitable label identifying this value A suitable label identifying this value (e.g. pharmacy, claims, member services, behavir health) A suitable label identifying this value Mandatry Mandatry Optinal Back Back Back r left blank Disclaimer/Ntes N/A Optinal Back PDF417 N/A Optinal Back 1 Mst f the infrmatin used within sectin 1 is based upn the WEDI Health Identificatin Card Implementatin Guide v1.0 Page 4 f 15

5 UHIN Health Identificatin Card Standard Apprved Sectin 2 Essential Infrmatin and Design Cmmn t the Health Identificatin Card Cnventins Placement f variable infrmatin elements - Printed, variable infrmatin elements are lcated n the frnt side f the health identificatin card. The back side f the health identificatin card generally cntains cnstant infrmatin. Hwever, except fr essential infrmatin r where explicitly stated therwise, the card issuer has discretin. Labels - Labels are required when specified fr the crrespnding infrmatin element. Labels are generally smaller r less bld than infrmatin elements. Labels may be abve r t the left f their crrespnding infrmatin element as lng as there is clear assciatin. Language - Labels and pre-printed infrmatin shall be in English. Redundant labels r ther infrmatin may be repeated in anther language in additin t English. Character set - Except where therwise specified, infrmatin elements are alphanumeric. See UHIN Individual Name Standard. Date Frmat If used (ptinal) machine-readable dates are all ccyymmdd. Physical characteristics - Refer t sectin 3. Embedded spaces in identifiers - It is gd practice fr printed identifiers, such as the card issuer identifier r the cardhlder ID, t include embedded spaces r hyphens t assist readability; hwever, spaces r hyphens are nt included in machine-readable identifiers n the card r in electrnic transactins. They are nt significant; fr example, identifiers and are the same. Cmputer applicatins shuld remve spaces and hyphens befre prcessing. Card Size - Card size is apprximately inches by inches; hwever, exact dimensins are specified in the ISO 7812 identificatin card standards included by reference in the specificatins fr machine-readable technlgies. Fnt Size - Fnt size f eight (8) pints r greater must be used when printing mandatry data elements n the ID card. There is nt a specific fnt style, hwever the fnt shuld clearly differentiate letters vs. numbers (e.g., alpha O vs. numeric 0 and alpha I vs. numeric 1.). The mandatry data elements shuld be printed in uppercase fnt and nn-italic style. 2.2 Cardhlder Name ID & Name are the Same Persn. By definitin, the cardhlder name shall crrespnd with the cardhlder identifier. The cardhlder name and identifier shall identify the same persn r ther bject. The tw being the same is a defining attribute f the term, cardhlder. See Appendix B. Dependent Names. Refer t Appendix B fr descriptin f dependent names. Frmat. The printed cardhlder name shall fit n a single line; therwise, length f printed name is nt specified. In printed frm, it shall be frmatted in sequence f: given name, initial, surname, and suffix, separated by spaces. A hyphen r apstrphe may be significant in a name; s they may be included in bth printed and machine-readable frms. Punctuatin, such as a perid r cmma, is discuraged. Fr example: JOHN Q SMITH JR D MICHAEL JONES JANE E MILLER-SMITH 2 Mst f the infrmatin used within sectin 2 is based upn the WEDI Health Identificatin Card Implementatin Guide v1.0 Page 5 f 15

6 UHIN Health Identificatin Card Standard Apprved Truncatin. If full name is t lng fr space available, this implementatin guide recmmends the fllwing sequence t reduce the length f the name until it fits. This sequence retains the suffix, at least ne initial fr the given r middle name, whichever appears mst imprtant, and as much f the surname as space permits. If the given name is mre than an initial, truncate the middle name frm the right as needed but leave at least the middle initial. Then if the name still exceeds the space, truncate the given name frm the right as needed but leave at least its initial. If the name still exceeds the space, eliminate the middle initial. If the given name began as nly an initial, truncate the middle name frm the right as needed but leave at least the middle initial. If the name still exceeds the space, eliminate the given name initial. If bth the given and middle names began as initials r empty, eliminate the middle initial. If the name still exceeds the space, truncate the surname frm the right as needed until the name fits. Recmmend Printed & Machine-Readable Names be the Same. In rder t reduce a surce f cnfusin, this implementatin guide recmmends that where practical the printed and machine-readable cardhlder names be the same. Exceptins include: (1) there may be less space available fr a machine-readable name than a printed name r vice versa; (2) accented characters are nt permitted in machine-readable names. Acceptability f Name n Transactins. If cmpnents f a name must be truncated, this implementatin guide recmmends the card issuer accept either the name r truncated name n all transactins, including standard, paper, and DDE transactins. Check digit: The check digit is the last digit f the identifier and is calculated n the full card issuer identifier, including the implicit prefix, as described in Attachment B. Spaces and hyphens: Spaces shwn are helpful fr readability, but spaces r hyphens shall nt be significant ID characters. Fr example, is the same as Standard Label fr Card Issuer Identifier. The label shall include the ISO prefix as part f requirements in ISO card standards when Natinal Health Plan Identifier is implemented. 2.3 Placement f Essential Infrmatin The infrmatin elements called Essential Infrmatin shall be lcated n frnt f the card, with n ther infrmatin elements interspersed between them. 1. Cardhlder Name 2. Cardhlder Identifier 3. Card Issuer Identifier 4. Office C-Pay 5. Specialty C-Pay 6. Yearly Deductible 7. State Regulated Page 6 f 15

7 UHIN Health Identificatin Card Standard Apprved Figure 1 Placement f Essential Infrmatin Essential Infrmatin justified t left margin Infrmatin may be higher r lwer vertically alng the left margin. N ther infrmatin may be interspersed between infrmatin elements Subscriber SUSAN J SMITH ID ABC Issuer (80840) Office C-Pay $0.00 Specialty C-Pay $0.00 Yearly Deductible $0.00 State Regulated Infrmatin may be higher r lwer vertically alng the right margin. N ther infrmatin may be interspersed between infrmatin elements Space abve r belw the essential infrmatin may be used at the discretin f the card issuer (see card elements) Page 7 f 15

8 UHIN Health Identificatin Card Standard Apprved Sectin 3 Data Structure fr Machine-Readable Infrmatin Standard Data Structure Data Max Length Frmat Required Repeat Start Sentinel 1 Fixed % Required Frmat Cde 2 Fixed WH Required Card Issuer Identifier 10 Fixed Numeric Optinal (required when the health plan ID is mandatry) Cardhlder ID 20 Variable Alphanumeric Required Number Field Separatr 1 Fixed ^ Required Cardhlder 36 Variable Alphanumeric Required Name Cmpsite Discretinary Optinal 0-72 Data Lp: Field Separatr 1 Fixed ^ Situatinal Qualifier Cde 2 Fixed Alphanumeric Situatinal Qualified Data 30 Variable Alphanumeric Situatinal End Sentinel 1 Fixed? Required Lngitudinal Redundancy Check 1 Fixed Any 7-bit cmbinatin Required Frmat cde. This 2-character cde indicates the structure f machine-readable data n the card. The same standard frmat is used regardless f technlgy. Advantages f this cde include: (i) cmputer is able t determine the card is a health ID card and (ii) permits the standard frmat t be changed, if necessary, in the future. Variable Data Element Length and Delimiters. Variable data elements are left justified and nt padded with extra spaces t the right. The card issuer shall ensure that n data element cntains the field separatr character ( ^ ) r End Sentinel (? ). Ttal Length. Ttal number f characters depends n field length, presence f the discretinary data lp, and technical factrs. Date frmat. Use ccyymmdd fr all dates, withut spaces, slashes, r hyphens. Card issuer identifier, 10-digit ISO Standard U.S. Healthcare Identifier withut prefix. Refer t Appendix B. Cardhlder identifier. Assigned by card issuer. Maximum length f 20 and may nt include spaces, hyphens, r ther special characters. 3 Mst f the infrmatin used within sectin 3 is based upn the WEDI Health Identificatin Card Implementatin Guide v1.1 Page 8 f 15

9 UHIN Health Identificatin Card Standard Apprved Cardhlder name. Name crrespnding t cardhlder identifier. Includes hyphen r apstrphe when significant as in JONES-SMITH r O NEILL. The machine-readable cardhlder name may nt include accented characters accented characters shall be replaced by their base character values. Cardhlder name uses cmpsite name frmat cnsisting f Surname / Given Name / Middle Name / Suffix, in which / is delimiter between cmpnents f the name. Fr example, JOHN Q PUBLIC JR is PUBLIC/JOHN/Q/JR. Use surname when a persn has nly a single name. N cmpnent may cntain the delimiter, /. A duble middle name is 1 cmpnent. Remve leading and trailing spaces frm all cmpnents. Empty fields are null. Fr example, JOHN PUBLIC JR is PUBLIC/JOHN//JR. D nt end with delimiters. Fr example, JOHN PUBLIC (n middle name, n suffix) is PUBLIC/JOHN. 3.2 Discretinary data lp The discretinary data lp is included fr the date f birth f the cardhlder. An entry, in the discretinary additinal data lp cnsists f three elements: a field separatr, a qualifier cde, and qualified data. Qualifier Cde Occurs Descriptin Cardhlder DOB DB 0-1 Date f birth f cardhlder. Frmat ccyymmdd 3.3 Example f Machine-Readable Data This example illustrates hw data shuld be represented in the standard machine-readable data structure. Example: Card Issuer (Left blank because it is ptinal) Cardhlder ID XJBH3AB572 Cardhlder Name JOHN Q PUBLIC Date f Birth (Left blank because it is ptinal) Start Cdes Data Cmmn t All Cards Discretinary Lp Start Frmat Card Issuer Cardhlder Cardhlder Qual DOB End LRC Cde ID Name Cde % WH XJBH3AB572 ^ Public/Jhn/Q ^? X Page 9 f 15

10 UHIN Health Identificatin Card Standard Apprved Number f characters: Req Req Optinal Required Required Discretinary Lp Req Req (Optinal) fixed fixed fixed Variable F variable F fixed variable F F Ttal Characters 40 1) Number f characters. Number f characters in example as shwn 40 Number f characters if name were characters: Space Remaining Health Identificatin Card t X Healthcare Eligibility Benefit Inquiry Mapping Please see Appendix C. Page 10 f 15

11 UHIN Health Identificatin Card Standard Apprved Sectin 4 Sample Health Identificatin Cards Health Identificatin Card (Medical Only) Sample Card Frnt Side ABC HEALTH PLAN XYZ NETWORK Emplyer Medical C-Pay $0.00 Specialty C-Pay $0.00 Subscriber Yearly Deductible $0.00 SUSAN J SMITH ID ABC Issuer (80840) Sate Regulated Back Side with PDF417 Barcde THIS CARD DOES NOT GUARANTEE COVERAGE Paper Claims t: Imprtant Numbers: ABC Health Plan Help Desk (800) Main 454 East Prir Auth (800) SLC, UT Pharmacy (800) Page 11 f 15

12 UHIN Health Identificatin Card Standard Apprved Health Identificatin Card (Medical Only) Sample Card with dependents Frnt Side ABC HEALTH PLAN XYZ NETWORK Emplyer Dependents 02 Jhn Smith 03 Ann Smith Subscriber SUSAN J SMITH Office C-Pay $10.00 ID Specialty C-Pay $0.00 ABC Deductible $0.00 Issuer (80840) State Regulated Back Side with PDF417 and Data Matrix THIS CARD DOES NOT GUARANTEE COVERAGE Paper Claims t: Imprtant Numbers: ABC Health Plan Help Desk (800) Main 454 East Prir Auth (800) SLC, UT Pharmacy (800) Page 12 f 15

13 UHIN Health Identificatin Card Standard Apprved Appendix A Pharmacy and/r Cmbinatin Identificatin Card Guidance Pharmacy and/r Cmbinatin ID cards are currently utside the scpe f this UHIN Health Identificatin Card Standard. T assist trading partners wh chse t use a pharmacy and/r cmbinatin (e.g. medical and pharmacy) ID card, trading partners are encuraged t use the NCPDP 4 Health Care Identificatin Card (Pharmacy and/r Cmbinatin ID Card) Implementatin Guide versin 2.0 fr additinal guidance. The NCPDP Health Care Identificatin Card is an existing implementatin guide used within the pharmacy industry: Cmbinatin ID Cards. Sample Pharmacy and/r Cmbinatin ID Cards. Nn-Mandatry and Excluded Data Elements. 4 Natinal Cuncil fr Prescriptin Drug Prgrams Page 13 f 15

14 UHIN Health Identificatin Card Standard Apprved Appendix B Basic Health Identificatin Card Definitins Administrative Services Only (ASO) r Third Party Administratr (TPA) Name - A cntracted entity wh handles claims prcessing and/r administratin. Alphanumeric - Uppercase letters frm A t Z, numeric characters, space(s) and special characters. Back Side f the Card - The card face ppsite frm the frnt f the card. Card issuer identifier The card issuer identifier is an ISO Standard U.S. Healthcare Identifier assigned by an enumeratr authrized under ISO/IEC Standard It is anticipated that the standard card issuer identifier will ultimately be the Natinal Health Plan ID, until that time ther ISO/IEC Standard 7812 identifiers may be used. The full card issuer identifier includes an implicit prefix NNNN NNN NNC, where: = preprinted ISO prefix: 80 = health applicatin, 840 = United States NNNN NNN NNC = PlanID, Standard Health Plan Identifier, r = ther, e.g. Standard Trading Partner Identifier C = check digit Card Issuer Name The authrized entity issuing the card. Cardhlder ID The plicy hlder number issued by the plan. Cardhlder Name The plicy hlder s name r dependent. Dependents An individual cvered under the plicy hlder s plan. Emplyer Name Spnsr f the benefit plan Frnt Side f Card - Face f the card carrying visual infrmatin cntaining the card issuer and cardhlder identifiers. Human-readable The alphanumeric infrmatin cntained n the Health Identificatin card. Machine-readable The PDF417 infrmatin cntained n the Health Identificatin card. Netwrk Affiliatin The cntract netwrk (e.g. physician, facility) Numeric - Digits 0 t 9. Plan Name The brand name under which benefits are administered. Special Characters - Special characters are defined as:! ^ & * ( ) - = + { } [ ] < >,.? /. A special character is remved frm this categry when it is used as a delimiter. 5 ISO / IEC 7812 Identificatin cards Identificatin f issuers, Part 1: Number system, 4.2.3; and Part 2: Applicatin and registratin prcedures. Adpted by INCITS (Internatinal Cmmittee fr Infrmatin Technlgy Standards) as an American Natinal Standard; date f ANSI Apprval March 27, Page 14 f 15

15 UHIN Health Identificatin Card Standard Apprved Appendix C Health Identificatin Card t X Healthcare Eligibility Benefit Inquiry Mapping This mapping dcument may be used by prviders t assist with the develpment f the X Healthcare Eligibility Benefit Inquiry based n the machine-readable infrmatin cntained n the PDF417 bar cde. UHIN Health Identificatin Infrmatin Element Issuer ID (80840) Cardhlder ID Cardhlder Name X Segment ID X12 Field Qualifier X Field Lp 2100A NM1 Infrmatin Surce Name Lp 2100C NM1- Subscriber Name Lp 2100C NM1- Subscriber Name Lp 2100A NM108 ="XV"- HCFA Natinal Plan ID (when it becmes available) NM108="MI"- Member Identificatin Number N Qualifier Applies Lp 2100A NM109 Lp 2100C r 2100D- NM109 Lp 2100C r 2100D- NM 104= First Name Lp 2100C r 2100D NM105 = Middle Initial Lp 2100C r 2100D NM 103 = Last Name Page 15 f 15