Monday, February 27, 2017
EDI 270 5010 Health Care Eligibility Benefit Inquiry
EDI 270 5010 Health Care Eligibility Benefit Inquiry
If you are new to Medical Billing, then please read this article first.
If you are new to EDI, then read the following articles
1. What is an EDI ?
2. EDI Transactions
3. Understanding EDI Structure
4. EDI Instruction
Introduction
For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed and need to be implemented consistently by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.
Providers of medical services must currently submit health care eligibility and benefit inquiries in a variety of methods, either on paper, via phone, or electronically. The information requirements vary depending upon:
The Health Care Coverage, Eligibility, and Benefit transactions are designed so that inquiry submitters (information receivers) can determine (a) whether an information source organization (e.g., payer, employer, HMO) has a particular subscriber or dependent on file, and (b) the health care eligibility and/or benefit information about that subscriber and/or dependent(s). The data available through these transaction sets is used to verify an individual’s eligibility and benefits, but cannot provide a history of benefit use.
This paired transaction set is comprised of two transactions: the 270, which is used to request (inquire) information, and the 271, which is used to respond with coverage, eligibility, and benefit information. The official names for these transactions are:
ANSI ASC X12.281 - Eligibility, Coverage, or Benefit Inquiry (270)
ANSI ASC X12.282 - Eligibility, Coverage, or Benefit Information (271)
The 270 document typically includes the following:
The ASC X12N Specification - 5010 Version
1. EDI 270–5010 Documentation - ISA – Interchange Control Header
2. EDI 270–5010 Documentation – GS – Functional Group Header
3. EDI 270–5010 Documentation – ST – Transaction Set Header
4. EDI 270–5010 Documentation – BHT – Beginning Of Hierarchical Transaction
5 EDI 270–5010 Documentation – HL – Hierarchical Level
6. EDI 270–5010 Documentation–2100A Information Source Name
7. EDI 270–5010 Documentation–2000B Information Receiver Level
8. EDI 270–5010 Documentation–2000B Information Receiver Name
9. EDI 270 – 5010 Documentation-2000C Hierarchical Level
10. EDI 270 – 5010 Documentation – Subscriber Trace Number
11. EDI 270 – 5010 Documentation – 2100C SUBSCRIBER Name
EDI Examples
Please note ; all these examples are tested against WPC First Pass software.
You can download trial version here.
Also, you can download the following trial version software to view/validate EDI File.
1. EDI Notepad2. HIPPA Document Viewer 2
3. On Line Validator American Coders
4. On Line Validator EDIVance
The following open source converts X12 EDI File to XML and 1500.
OopFactory X12 Parser
The following URL discuss about other open source in EDI Software.
Comparing Open Source EDI Software
Sample EDI 270 5010. For clear understanding, line separator are used between loops
ISA*03*id27032743*01*XYXY2233 *ZZ*XX09211223 *01*030240928 *130829*1102*^*00501*290811021*0*T*:~
GS*HS*XX09211223*030240928*20130829*1102*1*X*005010X279A1~
ST*270*0001*005010X279A1~
BHT*0022*13*0001*20130829*1102~
HL*1**20*1~
NM1*PR*2*FLORIDA BLUE*****PI*BCBSF~
HL*2*1*21*1~
NM1*1P*2*Bella Vista Health Center*****XX*1306849724~
HL*3*2*22*0~
TRN*1*290811021*3030240928~
NM1*IL*1*MULLIN*DANIEL****MI*XJBH12345678~
DMG*D8*19571112~
DTP*291*D8*20130829~
EQ*30~
SE*13*0001~
GE*1*1~
IEA*1*290811021~
Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com.
Available link for download
Thursday, February 9, 2017
EDI 5010 Documentation 837 Professional Loop 2430 Line Adjudication Information
EDI 5010 Documentation 837 Professional Loop 2430 Line Adjudication Information
This loop is required only if current insurance sequence > 1. i.e. for secondary, tertiary, etc.
Say for example, if the current insurance is secondary, then we should run this loop for the primary insurance. If the current insurance is tertiary, then we should run this loop for the primary and then secondary insurance. And also so on. In general, take the sequence number of the current insurance, and run this loop for all the previous sequence insurance.
We need to repeat this loop for each line item in the claim.
When submitting coordination of benefits (COB) claims to Secondary Payer, the prior payer’s payment information must be included in the 837 claim file. There is important edit takes places in COB Claims at line item level for balancing the amounts.This edit is to verify that each charge line balances with the payment information at the line level. An example of line level balancing is below. The data in red provides an example of how the line level must balance.
Service Level (Loop 2400) line item charge amount Professional (SV102) or line item charge amount Institutional (SV203) = the sum of all other payer service line paid amounts (SVD02) at the service level (Loop 2430) + the sum of all the service line adjustments (CAS03) at the service level (Loop 2430)
Line level balancing:
SV1*HC:90834*137*UN*1***1:2:3
DTP*472*D8*20130513
SVD*99726*47.28*HC:90834**1
CAS*CO*45*77.86
CAS*PR*2*11.86
137 = 47.28 + 77.86 + 11.86
If there is balancing issue, then you will receive “Secondary Claim Information Missing or Invalid - Each line must balance; Line Charge Amount = Line Sum Of Adjustment Amounts + Line Payer Paid Amount”
| Loop | Seg ID | Segment Name | Format | Length | Ref# | Req | Value |
| 2430 | SVD | Line Adjudication Information | ID | 3 | S | SVD | |
| Element Separator | AN | 1 | * | ||||
| SVD01 | Identification Code | ID | 1/2 | 1033 | R | PR | |
| Element Separator | AN | 1 | * | ||||
| SVD02 | Monetary Amount | ID | 1/5 | 1034 | R | 1 | |
| Element Separator | |||||||
| SVD03-1 | Product/Service ID Qualifier | ID | 2 | 235 | R | HC | |
| Component Element Separator | 1 | : | |||||
| SVD03-2 | Product/Service ID | 2 | Procedure Code | ||||
| Component Element Separator | 1 | : | |||||
| SVD03-3 | Procedure Modifier | AN | 2 | 1339 | Modifier1 | ||
| Component Element Separator | 1 | : | |||||
| SVD03-4 | Procedure Modifier | AN | 2 | 1339 | Modifier2 | ||
| Component Element Separator | 1 | : | |||||
| SVD03-5 | Procedure Modifier | AN | 2 | 1339 | Modifier3 | ||
| Component Element Separator | 1 | : | |||||
| SVD03-6 | Procedure Modifier | AN | 2 | 1339 | Modifier4 | ||
| Component Element Separator | 1 | : | |||||
| SVD03-7 | Description | Not Used | |||||
| Element Separator | * | ||||||
| SVD04 | Description | Not Used | |||||
| Element Separator | * | ||||||
| SVD05 | Quantity | R | Line Item Unit | ||||
| Segment Terminator |
2430 Line Adjustment CAS - Deductible
| Loop | Seg ID | Segment Name | Format | Length | Ref# | Req | Value |
| 2430 | CAS | Line Adjustment | ID | 3 | S | CAS | |
| Element Separator | AN | 1 | * | ||||
| CAS01 | Claim Adjustment Group Code | ID | 1/2 | 1033 | R | PR | |
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