Streamlining Health Care Administrative Transactions in Minnesota
AUC ELIGIBILITY TAG AGENDA – Revised 1-26-16
Wednesday, January 27, 2016
2:00 p.m. – 4:00 p.m.
Teleconference line: 1-712-832-8300
Participant passcode: 337213
WebEx instructions:
1. To start the WebEx session, go to: https://health-state-mn-ustraining.webex.com
2. Under “Attend a Session,” click “Live Sessions”
3. Click on the session for “AUC Eligibility TAG”
4. Provide your name, email address, and the following password: Elg2010! (Note: The exclamation
mark at the end is part of the password.)
5. Click “Join now”
Meeting Objectives:
•
Review and discuss Limited exception for non-HIPAA payers from Minnesota's requirements for
270-271 transactions and discuss possible submission to X12 for missing information
•
Review Eligibility Survey results to determine if all pain points had been addressed
•
Develop Eligibility 2016 Work Plan
•
Discuss AAA errors scenarios for Ops consideration
Agenda items
1. Meeting to order – Kathy Harvey, co-chair
2. Anti-trust statement: http://www.health.state.mn.us/auc/pdfs/antitrust.pdf
3. Introductions - Please e-mail your attendance to [email protected]
4. Review of 2015 Accomplishments
5. Discuss limited exception and possible submission to X12 for non-HIPAA exception
6. Develop Eligibility 2016 Work Plan
a. 2016 calendar – how often to meet?
b. Should TAG work on barriers identified in NCVHS?
c. Do best practices address all pain points in 2015 survey?
d. Is there interest to develop AAA errors scenarios?
e. TAG submission to AUC newsletter re Eligibility transactions?
7. Other Business
Next Meeting - TBD
Teleconference/WebEx only
AUC Eligibility TAG
2015 Review
10 AUC Related Meetings
Eight regularly scheduled
meetings
Two special meetings to
prepare response to NCVHS
regarding Operating Rules
Best Practices
 Service Type 60 Response
(Active Coverage, No Benefits
Reported)
 Reporting Termination Date for
Inactive Coverage
 Service Type Inquiry/Response
Limited Exception Rule
Reviewed and approved for
2016 continuation of the
limited exception for nonHIPAA payers from
Minnesota’s requirements for
only the standard, electronic
exchange of Eligibility
transactions (270-271)
AUC Eligibility TAG
2016 Work Plan
Considerations for TAG’s 2016 Work Plan -1
• Barriers identified in NCVHS June 2015 submission
• Development of AAA errors scenarios
• Article for submission in AUC newsletter re Eligibility
transactions
Considerations for TAG’s 2016 Work Plan -2
• 270/271 Annual Maintenance
• Outstanding pain points identified in TAG’s surveys
• TAG’s meeting calendar for 2016
• How often to meet?
• In-person meeting?
QUESTIONS
1. Approve continued exception
from eligibility requirements
for entities not covered by
HIPAA
The statutory exception to rules for the exchange of the
eligibility inquiry and response transaction (270/271) only, a
provision in 62J.536, must be renewed annually. This limited
exception applies to all payers and providers not subject to
federal HIPAA regulations when the transaction doesn’t meet
business needs or if there is another, better transaction that
can be used. The Eligibility TAG has reviewed and approved
the continued exception for 2016.Ops need to approve.
It was suggested that the Eligibility TAG submit a request to
X12 to add those missing data elements to the transaction.
Ann will have Eligibility consider preparing a request to X12.
Kathy received sale solicitation – selling Eligibility product. Laid out very nicely. On 271 displays medical benefits, 30 describes medical
benefits and (product and taken into the product
Only want to know what they should collect for service/vendors can do better job of customization
Eligibility TAG Pain Points/Issues for 2015 Work Plan
Issue/Concern
Registration and verification staff not receiving policy expiration dates
with an inactive status (frustrations of our registration and verification
staff)
Obtaining necessary mental health benefits in the eligibility response
(Have to call payer because all info was not provided)
Payer contact information to address complex EDI problems
Conflicting patient insurance information by various sources
Conflicting benefit information, e.g. $500 deductible vs. no deductible
Are they complicated benefits; sometimes
$200 hospital outpatient/outpatient CT $0
Depends on the group plan/some procedures may not be reported
Ability for health plans (payers) to perform eligibility transactions
More standardization of benefit information for most critical benefit
type codes (Example: mental health – if you request service type MH
only you will not get all the needed benefit)
Establishment of service type packages to request complete benefits
and receive helpful (meaningful) replies (Example from EDI: Why does a
service type code of 30 get a large range of benefits?)
Better communication around eligibility problems without clearly
defined AAA errors.
Solution
Review 2012 best practices draft/need consistency and
perhaps two or more options for TAG to review and
discuss
Best practice to explain what provider should be getting
and/or group services together
Information in payer’s companion guide/BCBS generate
tickets for EDI assistance/could require part of
companion guide/within 271??/Specific code to escalate
(refer) to EDI staff more quickly or directly
Usually issue with Medicaid/managed care plan/
(perhaps can address with DHS) – contact help desk or
Clark—Timeline when payers receive eligibility updates
PMAP programs
MNITs
Look at eligibility implementation guide/business
function (Mary Lee/Aetna)
Call B.J. (Judy)
The best practice would be to request service type
codes, MH, A4, A5, A6, A7 & A8 (Tim is drafting)
Expectations at the insurance company and providers
office are similar (Tim is drafting)
Trading partners could agree for error X we will use
error code Y. This allows more effective troubleshooting
of errors from providers and health insurance
companies (Might be able to define high level scenarios
but would that be helpful if CHs aren’t required,
especially when going through several CHs; CH reformat)
guide does not provide for granularity—Might be
difficult to resolve at this time
Do providers have specific scenarios to be addressed?
Best Practice/Guide/AUC
Website
X
X
X
271 Eligibility Response Transaction
AAA Segment Error Resolution Process
For Leased-Line, Dial-Up & Batch
This document details a four-step process to help determine what data elements or data fields are in error when a
271 Response transaction is returned to a provider, submitter or clearinghouse which contains AAA segments. A
271 Response transaction containing AAA segments indicates that the 270 Eligibility Request transaction previously
submitted to Medi-Cal was rejected due to data errors or was processed but could not return any eligibility
information for the Subscriber. The AAA segment contains the reason for the rejection or why there is no eligibility
information for the Subscriber in the response.
Step #1
Review the rejected 271 Response transaction (refer to the example below).
The following segment headings are contained in this response and are indicated in bold:
ISA, GS, ST, BHT, HL, NM1, AAA, SE, GE and IEA (a caret (^) separates each segment, such as the caret before
GS, which is at the end of the ISA segment. Batch responses contain carets as segment separators whereas LeasedLine & Dial-Up returns Hex’0D’).
271 Example (w/o 864 Provider Mail)
2100A Loop with an NM108 Error
ISA*00*__________*00*__________*ZZ*610442_________*ZZ*XXX999999______*0
40722*0146*U*00401*000000001*0*P*~^GS*HB*610442*XXX999999*20040322*0146
2201*000000001*X*004010X092A1^ST*271*000000001^BHT*0022*11*TRACENUMB
ER*20040322*01462201^HL*1**20*1^NM1*PR*2*MEDI-CAL*****46*6104 42^AAA*N**
79*C^SE*0000000006*000000001^GE*1*000000001^IEA*1*000000001.
Locate the AAA segment (grey highlight).
Each AAA segment consists of (1) ‘AAA’, (2) a response code, (3) a reject code, and (4) a follow-up action code
(an asterisk separates each data element). Refer to “Note for Step #1” on a subsequent page for the code definitions.
************
A transaction can have multiple AAA segments.
In this example, there is only one AAA segment, and it has a response code of “N”;
a reject code of “79” and a follow-up action code of “C”.
************
Page 1 of 6
May 2007
Step #2
Review the rejected 271 Response transaction example used in Step #1 on the previous page. Step #2 is to identify
the level or loop in which the error occurred. Level or loop numbers do not appear in the transaction, but they
appear in the Companion Guide as logical groupings of data elements.
To determine which level or loop the AAA segment is in, look to the left of each AAA segment for an immediately
preceding segment heading of “HL”, “NM1”, “DMG”, “DTP” or “EB”.
If an “HL” immediately precedes the AAA segment, and a “1” is to the right of it, then the level = 2000A
(Medi-Cal information). In our example, this condition is not true.
If an “NM1” immediately precedes the AAA Segment, and a “PR” is to the right of it, then the level = 2100A
(Medi-Cal information). In our example, this condition is true.
If a “1P” is to the right of the NM1, then the level = 2100B (provider information). In our example, this condition is
not true.
If an “IL” is to the right of the NM1, then the level = 2100C (subscriber information). In our example this condition
is not true.
If a “DMG”, “DTP” or an “EB” immediately precedes the AAA segment, then the level = 2110C (subscriber
information). In our example, this condition is not true.
… ^NM1*PR*2*MEDI-CAL*****46*6104 42^AAA*N**79*C …^
In our response example, the AAA segment is immediately preceded by an NM1 segment, which has a “PR” (grey
highlight) to the right. Therefore, the AAA segment is in the 2100A level or loop.
************
Conclusion: The AAA segment is in the 2100A level/loop in this example.
************
Page 2 of 6
June 2005
Step #3
Search the lists on the following pages, using the level number and reject code to determine all the possible causes
of data element errors. Since the AAA segment in the example on page 1 is in the 2100A loop, the second grouping,
for 2100A, is the appropriate list to use. It indicates that reject code 79 means that the transmitted inbound data did
not have a “46” for data element NM108, or it did not have a “610442” for data element NM109, so as per the
Companion Guide - either 46 or 610442 were missing in the 270 Inquiry inbound transaction – refer to the example
in Step #4.
Refer to “Note for Step #3” on a subsequent page regarding how to read data elements.
If the AAA segment is in loop/level 2000A, match the reject code with a data element or data field code below.
Reject Code
Data Element/Field Code
41
ISA02 (invalid vendor ID &/or software version #)
41
ISA04 (for Leased-Line & Dial-Up only - PIN not found, not present, or invalid)
41
ISA06 (submitter/provider number not found, not present, or invalid)
79
ISA08 (ETIN not “610442”)
42
SYSPR (there was a system problem)
If the AAA segment is in loop/level 2100A, match the reject code with a data element or data field code below.
Reject Code
Data Element/Field Code
T4
NM101 (data is missing)
79
NM101 (data is not “PR”)
79
NM108 (data not “46”)
T4
NM108 (data is missing)
79
NM109 (data not “610442”)
42
SYSAV (system not available)
If the AAA segment is in loop/level 2100B, match the reject code with a data element or data field code below.
Reject Code
Data Element/Field Code
15
NM101 (data not “1P”)
15
NM102 (data not “1” or “2”)
15
NM108 (data not “SV” or “XX”)
43
NM109 (data not present)
43
NM109 (for Leased-Line & Dial-Up does not match ISA06)
51
NM109 (Provider not on File – NPI or Medi-Cal Provider Number)
50
NM109 (for Online: (Provider on file but not active)
15
REF01 (for Batch only – REF not “4A”)
43
REF02 (for Batch only - REF02 not present or Invalid Provider PIN)
Page 3 of 6
May 2007
If the AAA segment is in loop/level 2100C, match the reject code with a data element or data field code below.
Reject Code
Data Element/Field Code
15
NM101 (data not “IL”)
15
NM102 (data not = “1”)
15
NM108 (data not “MI”)
72
NM109 (Invalid or missing Subscriber ID)
75
NM109 (Subscriber ID not on file)
15
DMG01 (data not “D8”)
58
DMG02 (invalid/missing date of birth)
15
DTP01 (for Leased-Line & Dial-Up only - data not “102” or “472”)
15
DTP02 (data not “D8”)
57
DTP03 (invalid/missing date of service)
56
DTP03 (inappropriate date – Invalid/missing Issue Date)
42
System not Available (for Batch only)
If the AAA segment is in loop/level 2110C, match the reject code with a data element or data field code below.
Reject Code
Data Element/Field Code
15
AMT01 (data not “R” or “PB”)
15
AMT02 (invalid dollar amount)
56
DTP03 (inappropriate date – Invalid Issue Date)
62
DTP03 (Date of Service not in allowable range)
63
DTP03 (Date or Service in the future)
************
Conclusion: Either NM108 or NM109 is in error in the 270 Inquiry Transaction.
************
Page 4 of 6
May 2007
Step #4
Review the original 270 Inquiry transaction (example below).
In this example, there are the following segments (bolded):
ISA, GS, ST, BHT, HL, NM1, HL, NM1, HL, TRN, TRN, NM1, REF, DMG, DTP, DTP, EQ, SE, GE and IEA
270 Example
ISA*03*__________*01*1234567___*ZZ*XXX999999_____*ZZ*610442EDS214___*04
0213*0634*U*00401*000000001*0*P*~^GS*HS*XXX999999*610442*20040213*06340
558*000000002*X*004010X092A1^ST*270*000000003^BHT*0022*13*004*20040203*
06340558^HL*1**20*1^NM1*PR*2*MEDI-CAL*****99*610442^HL*2*1* 21*1^NM1*1P
*1******SV*XXX999999^HL*3*2*22*0^TRN*1*123456^TRN*1*654321^NM1*IL*1******M
I*555555555^REF*EA*66612107^DMG*D8*19500204^DTP*472*D8*20040402^DTP*1
02*D8*19900527^EQ*30^SE*0000000016*000000003^GE*1*000000002^IEA*1*00000
0001.
Determine the EXACT cause of the data element error. Notice that in the above 270 example the NM108 data
element/field is “99” (grey highlight). This is erroneous data in the 270 Inquiry transaction. It should be “46”.
************
Conclusion: Since NM109 does have “610442”, and “NM108 (bolded in example in Step #4) has a “99”, then
NM108 was in error in the 270 inbound Inquiry transaction.
************
Only correct values are returned in the 271 Response transaction by Medi-Cal. Erroneous data is never returned.
Frequently, the 271 Response fields are left blank because Medi-Cal does not know what the correct value(s) should
be. NM108 had a “99” in the 270 inbound, so the 271 response has the correct value: “46”.
Accordingly, the AAA segment in the 271 Response transaction has a response code of “N” (data error) and a
follow-up action code of “C” (correct and resubmit).
Page 5 of 6
May 2007
Note for Step #1
Response Code Definitions:
N = A data element was erroneous.
Y = The transaction was rejected for some other reason (such as system unable to respond).
Follow-Up Action Code Definitions:
C = Correct and resubmit.
N = Resubmission not allowed.
P or R = Please resubmit original transaction or resubmission allowed.
Note for Step #3
Each data element code consists of the segment header (“NM1” for example) followed by a data element number
(“01” through “16”). The data element numbers after each segment header can progress from 01 to 16. An asterisk
separates each data element in a transaction and any omitted data element has an asterisk in its place. This is
explained in detail on page 2 of each of the data specification documents in the Companion Guide.
For additional assistance, contact the Telephone Service Center (TSC) at 1-800-541-5555.
Page 6 of 6
October 2004
CareFirst BlueCross BlueShield
CareFirst BlueChoice, Inc.
HIPAA 270/271
Transactions & Code Sets
Companion Guide (Version 1.1)
To the HIPAA X12 Implementation Guide
(Version 005010X279A1)
December 18, 2012
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
CUT0281-1E (12/12)
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
Disclosure Statement
This Companion Guide is issued in an effort to provide Trading Partners of CareFirst BlueCross BlueShield and
CareFirst BlueChoice, Inc., collectively known as “CareFirst,” with the most up-to-date information related to
standard transactions. Any and all information in this guide is subject to change at any time without notice. Each
time you test or submit a standard transaction, we recommend that you refer to the most recently posted
Companion Guide to ensure you are using the most current information available.
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
Preface
This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under
HIPAA clarifies and specifies the data content when exchanging electronically with CareFirst. Transmissions
based on this companion guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant
with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is
within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion
Guide is not intended to convey information that in any way exceeds the requirements or usages of data
expressed in the Implementation Guides.
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
Table of Contents
1. Introduction..................................................................................................................................………………..1
1.1
Scope.............................................................................................................................................................. 1
1.2
Overview ......................................................................................................................................................... 1
1.3
References ...................................................................................................................................................... 1
1.4
Additional Information ..................................................................................................................................... 1
2. Getting Started.................................................................................................................................................... 2
2.1
Working with CareFirst .................................................................................................................................... 2
2.2
Trading Partner Registration ........................................................................................................................... 2
2.3
Certification & Testing Overview ..................................................................................................................... 2
2.4
Production Status ............................................................................................................................................ 2
3. Testing ................................................................................................................................................................. 3
4. Connectivity/Communications.......................................................................................................................... 4
4.1
Process Flows ................................................................................................................................................. 4
4.2
Transmission Administrative Procedures ....................................................................................................... 4
4.2.1
Schedule, Availability and Downtime Notification ................................................................................. 4
4.2.2
Re-Transmission Procedures ............................................................................................................... 5
4.3
Communication Protocol Specifications ......................................................................................................... 5
4.4
Passwords....................................................................................................................................................... 5
5. CareFirst Contact Information .......................................................................................................................... 6
5.1
EDI Customer Service .................................................................................................................................... 6
5.2
EDI Technical Assistance ............................................................................................................................... 6
5.3
Provider Service Number ................................................................................................................................ 6
5.4
Applicable Web-sites/E-mail ........................................................................................................................... 6
6. Control Segments/Envelope ............................................................................................................................. 7
6.1
ISA-IEA ........................................................................................................................................................... 7
6.1.1
The 270 Eligibility/Benefit Inquiry .......................................................................................................... 7
6.1.2
The 271 Response ................................................................................................................................ 8
6.2
GS-GE............................................................................................................................................................. 9
6.2.1
The 270 Eligibility/Benefit Inquiry .......................................................................................................... 9
6.2.2
The 271 Response ................................................................................................................................ 9
6.3
ST-SE ........................................................................................................................................................... 10
6.3.1
The 270 Eligibility/Benefit Inquiry ........................................................................................................ 10
6.3.2
The 271 Response .............................................................................................................................. 10
7. CareFirst Business Rules and Limitations ................................................................................................... 11
7.1
Real Time Processing Mode ........................................................................................................................ 11
7.2
Single Patient Inquiry……………………………………………………………………………………… ............ 11
7.3
EQ Segment……………………………………………………………………………………………… ............... 11
7.4
DTP Segment……………………………………………………………………………………………………….. 11
7.5
Error Conditions ............................................................................................................................................ 11
8. Acknowledgements and/or Reports .............................................................................................................. 13
8.1
Report Inventory ........................................................................................................................................... 13
9. Trading Partner Agreements ........................................................................................................................... 14
9.1
Trading Partners ........................................................................................................................................... 14
10. Transaction Information .................................................................................................................................. 15
10.1
The 270 Eligibility/Benefit Inquiry ................................................................................................................. 15
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
10.2
The 271 Response ....................................................................................................................................... 20
11 Appendices……………………………………………………………………………………………………………. . 27
Implementation Checklist…………….…………………………………………………………………..……. . 27
271 AAA Error Codes.………………………………………………..………………………………………... .. 27
CareFirst 271 AAA Error Codes
HIPAA 271 AAA Error Codes
CareFirst Supported Service Type Codes………………..……………………………………………….…. . 27
Acronyms and Definitions………………………………………………………………………………............ . 27
Change Summary …………………..……………………………………….................................................. 27
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
1. Introduction
Under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act
(HIPAA) of 1996, the Secretary of the Department of Health and Human Services (HHS) is directed to adopt
standards to support the electronic exchange of administrative and financial health care transactions. The
purpose of the Administrative Simplification portion of HIPAA is enable health information to be exchanged
electronically and to adopt standards for those transactions.
1.1
Scope
This companion guide is intended for CareFirst Trading Partners interested in exchanging HIPAA
compliant X12 eligibility information (270/271 transactions) with CareFirst. It is intended to be used
in conjunction with X12N Implementation Guides and is not intended to contradict or exceed X12
standards. It contains information about specific CareFirst requirements for processing the 270/271
X12 transactions.
All instructions in this document are written using information known at the time of publication and
are subject to change. The most current version of the guide is available on the CareFirst website
at www.carefirst.com/electronicclaims.
1.2
Overview
This Companion Guide is issued in an effort to provide the CareFirst trading partners with the most
up-to-date information related to standard transactions. Any and all information in this guide is
subject to change at any time without notice.
This Companion Guide is applicable to all lines of business within CareFirst.
This document is designed to assist both technical and business areas of trading partners who wish
to exchange HIPAA standard 270/271 transactions with CareFirst, Inc. It contains specifications for
the transactions, contact information, and other information that is helpful.
All instructions in this document are written using information known at the time of publication and
will change as necessary to provide the most up-to-date information. The most up-to-date version
of the Companion Guide is available on the CareFirst website at
www.carefirst.com/electronicclaims.
CareFirst is not responsible for the performance of software outside of its installations.
1.3
References
This companion guide is an adjunct to the National Electronic Data Interchange Transaction Set
Implementation Guide Health Care Eligibility Benefit Inquiry and Response 270/271 ASC X12N
(005010X279A1)
1.4
Additional Information
Please be sure to always use the most current version of the companion guide available at
www.carefirst.com/electronicclaims.
Always feel free to contact CareFirst as described in Section 5.
1
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
2. Getting Started
2.1
Working with CareFirst
In general, there are three steps to submitting standard 270/271 transactions to the CareFirst
production environment.
Registration
Testing & Certification
Production Status
CareFirst accepts X12 standard transactions from any HIPAA covered entity with which it has an
agreement. Prior to approving the exchange of the 270/271 Transactions, the transactions are
tested according to a specific test plan. Results are verified by both parties. Once test results are
verified and approved, CareFirst advises the Trading Partner about submitting requests to the
production environment.
A submitter is typically a company that has Trading Partner status with CareFirst and is acting on
behalf of a group of HIPAA covered entities (e.g., a service bureau or clearinghouse) or is a
provider or a group health plan which has an agreement with CareFirst.
All potential CareFirst submitters must contact the EDI Operations Support Group (refer to the
CareFirst Contact Information in Section 5) to initiate action and authorization and to receive the
necessary information for proceeding.
2.2
Trading Partner Registration
To register to submit electronic transactions a Trading partner must contact CareFirst according to
the instructions in Section 5.
The requested information on Trading Partner Information Form (see Section 3) must be filled out
by the Trading Partner and emailed to the EDI Operations Support Group address listed in Section
5.
2.3
Testing & Certification Overview
CareFirst requires all potential submitters to participate in testing to ensure that transactions
produce the desired results. CareFirst supplies the test data and access information to the test
system. Successful completion and validation is an indication that all systems can properly submit
and receive the transactions.
2.4
Production Status
The EDI Operations Support Group will advise the new submitter when all conditions are satisfied
and submission of production transactions can begin. At that time a production certificate of trust
will be issued by CareFirst to the trading partner.
2
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
3.
Testing
CareFirst requires all potential submitters to participate in testing to ensure that transactions produce the
desired results. Successful completion and validation is an indication that all systems can properly
submit and receive the transactions.
The CareFirst EDI Operations Support Group coordinates the testing activities and provides a detailed
test plan and test data. Additional test cases may be added by the submitter.
The URL for submitting test transactions is:
https://webapptt.carefirst.com:443/QA2TIBCO-BC/EDI-X12
OR
https://webapptt.carefirst.com:443/QA2TIBCO-BC/SOAP
NOTE: There are different URL’s for test and production transactions. Test time is available from 9:00
AM to 5:00 PM ET Monday - Friday.
A listing of test 270 requests and expected 271 responses used during testing is to be provided to the
CareFirst test coordinator for review and validation as well as the test data. The successful completion of
testing is to be verified and approved by the EDI Operations Group.
Security is verified with a certificate of trust attached to each transaction and verification of submitting IP
address(es). CareFirst will provide a certificate of trust to the submitting trading partner. A separate
certificate will be available for testing. A production certificate will be issued at the successful completion
of testing. The Trading Partner must provide the IP address(es) used for both testing and production
submission of transactions.
The information below should be provided to CareFirst for setup so CareFirst can begin testing with
Submitters. CareFirst will need to receive this information at least 30 days in advance.
To submit to CareFirst:
Trading Partner Name:
Primary EDI Support Contact:
Primary EDI Support Contact Phone #:
Primary EDI Support Contact Email:
Primary EDI Support Contact Address:
City:
State, Zip:
TP Test/Production IP Address(es)
Submitting Transactions:
Transactions that will be submitted to
CareFirst by Trading Partner:
3
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
4.
Connectivity/Communications
4.1
Process Flows
Trading Partner
Transmits
270Inquiry to CF
CF Receives 270
& Verifies Trading
Partner
CF Verifies X12
Format &Content
CF Returns
271Response to
Trading Partner
CF Formats
271Response into
X12
CF Looks Up
Patient
Information
The above illustrates the basic flow of the 270 Inquiry and 271 Response transactions.
4.2
Transmission Administrative Procedures
4.2.1
Schedule, Availability and Downtime Notification
CareFirst production systems are available 24 hours per day, 7 days per week with the
exception of 1:00 AM EST through 9:00 AM EST each Sunday for the real-time
processing mode. There are no regularly scheduled downtimes except as indicated in the
prior statement. CareFirst Systems’ planned downtime will be communicated to all
Trading Partners via an email message sent at least one week prior to the event. The
following is an example of the message to be sent to announce planned downtime.
To: Trading Partners
From: CareFirst B2B Gateway
The CareFirst B2B Gateway will be unavailable on xx/xx/xxxx from x AM
to x PM for scheduled maintenance.
This outage will affect the following transactions: 270/271, 276/277.
We apologize for any inconvenience.
CareFirst Systems’ unplanned downtime will be communicated to Trading Partners by
email as soon as possible. A second email will be dispatched when the system becomes
available.
4
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
To: Trading Partners
From: CareFirst B2B Gateway
The CareFirst B2B Gateway is unavailable at this time due to a system
outage.
This outage affects the following transactions: 270/271, 276/277.
We apologize for any inconvenience.
A follow-up email will be sent when the system is once again available.
4.2.2
Re-Transmission Procedures
When a 270 inquiry transaction receives a reject code by CareFirst it must be corrected
and re-submitted by the provider.
4.3
Communication Protocol Specifications
CareFirst receives and transmits transactions using HTTP/S.
The URL for submitting production transactions to CareFirst is
https://webapp.carefirst.com:443/TIBCO-BC/EDI-X12
OR
http://webapp.carefirst.com:13001/TIBCO-BC/SOAP
NOTE: There are different URL’s for test and production transactions.
4.4
Passwords
Logon and passwords are replaced by the use of security certificates and verification of submitting
IP addresses. The Trading Partner must submit the certificate supplied by CareFirst with every
transaction. There are separate certificates for test and production.
CareFirst security is maintained on three levels:
1. Verification of a certificate of trust attached to each transaction
2. Verification of the IP address submitting the transaction (supplied by the submitter)
3. Verification of the Trading Partner Id (in the ISA segment) supplied by CareFirst.
5
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
5. CareFirst Contact Information
5.1
EDI Customer Service
All inquiries and comments regarding initiation, set-up, testing, and submission of HIPAA
transactions should be directed to [email protected]
Support for all EDI Transactions is provided by the HelpDesk during normal business hours at
877-526-8390 or at [email protected]
5.2
EDI Technical Assistance
All inquiries and comments regarding initiation, set-up, testing, and submission of HIPAA
transactions should be directed to [email protected].
Support for all EDI Transactions is provided by the HelpDesk during normal business hours at
877-526-8390 or at [email protected].
5.3
Provider Service Number
All inquiries and comments regarding initiation, set-up, testing, and submission of HIPAA
transactions should be directed to [email protected]
Support for all EDI Transactions is provided by the HelpDesk during normal business hours at
877-526-8390 or at [email protected]
5.4
Applicable Websites/E-mail
All inquiries and comments regarding initiation, set-up, testing, and submission of HIPAA
transactions should be directed to [email protected]
Support for all EDI Transactions is provided by the HelpDesk during normal business hours at
877-526-8390 or at [email protected]
The most current version of this companion guide is available at
www.carefirst.com/electronicclaims > Guides.
6
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
6. Control Segments/Envelope
6.1
ISA-IEA
6.1.1
The 270 Eligibility/Benefit Inquiry
This section describes the values required by CareFirst in the ISA and IEA segments.
IG Page
Reference
C.4
ISA01
Authorization
Information Qualifier
2
Must be “00”
C.4
ISA03
Security Information
Qualifier
2
Must be “00”
C.4
ISA05
Interchange ID Qualifier
2
Must be “ZZ”
C.4
ISA06
Interchange Sender ID
15
Must be Trading Partner ID
C.5
ISA07
Interchange ID Qualifier
2
Must be “ZZ”
C.5
ISA08
Interchange Receiver ID
15
Must be CareFirst ID
C.5
ISA09
Interchange Date
6
Must be YYMMDD
C.5
ISA10
Interchange Time
4
Must be HHMM
C.5
ISA11
Interchange Control
Standards Identifier
1
Must be “^’
C.5
ISA12
Interchange Control
Version
5
Must be “00501”
C.5
ISA13
Interchange Control
Number
9
C.6
ISA14
Acknowledgement
Indicator
1
9 digit unique number with a nonzero in the first position.
ISA13 must be identical to IEA02
Must be “0”
C.6
ISA15
Usage Indicator
1
C.6
ISA16
Component Element
Separator
1
C.10
IEA01
Number of included
Functional Groups
1/5
Must be “1”
C.10
IEA02
Interchange Control
Number
9/9
IEA02 must be identical to ISA13
6.1.2
X12 Element Name
Length
Valid Values/Notes/Comments
Must be “T” or “P”
NOTE: test system rejects P;
Production system rejects T.
Must be “:”
The 271 Response
This section describes the values returned by CareFirst in the ISA and IEA
segments.
7
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
IG Page
Reference
X12 Element Name
Length
Valid Values/Notes/Comments
B.3
ISA01
Authorization
Information Qualifier
2
“00”
B.4
ISA03
Security Information
Qualifier
2
“00”
B.4
ISA05
Interchange ID Qualifier
2
“ZZ”
B.4
ISA06
Interchange Sender ID
15
CareFirst ID
B.4
ISA07
Interchange ID Qualifier
2
“ZZ”
B.5
ISA08
Interchange Receiver ID
15
Trading Partner ID
B.5
ISA09
Interchange Date
6
YYMMDD
B.5
ISA10
Interchange Time
4
HHMM
B.5
ISA11
Interchange Control
Standards Identifier
1
“^’’
B.5
ISA12
Interchange Control
Version
5
“00501”
B.5
ISA13
Interchange Control
Number
9
ISA13 will be identical to IEA02
B.6
ISA14
Acknowledgement
Indicator
1
“0”
B.6
ISA15
Usage Indicator
1
“T” or “P”
B.6
ISA16
Component Element
Separator
1
Must be “:”
B.7
IEA01
Number of included
Functional Groups
1/5
“1”
B.7
IEA02
Interchange Control
Number
9/9
IEA02 will be identical to ISA13
8
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
6.2
GS-GE
6.2.1
The 270 Eligibility/Benefit Inquiry
This section describes the values required by CareFirst in the GS and GE segments.
IG Page
Reference
B.8
GS01
B.8
GS02
B.8
GS03
B.8
X12 Element Name
Functional Identifier
Code
Application Sender’s
Code
Length
Valid Values/Notes/Comments
2/2
Must be ‘HS’- Eligibility Coverage or Benefit
Inquiry
Must be Trading Partner ID. Trading
Partner ID must be appended with “R” for
this element only.
CareFirst ID
2/15
GS04
Application Receiver's
Code
Date
8/8
CCYYMMDD
B.9
GS05
Time
4/8
HHMMSS or HHMMSSD or HHMMSSDD
B.9
GS06
Group Control Number
1/9
B.9
GS07
1/2
B.9
GS08
1/12
Must be “005010X279A1”
B.10
GE01
1/6
Must be ‘1’
B.10
GE02
Responsible Agency
Code
Version/ Release/
Industry Identifier Code
Number of Transaction
Sets Included
Group Control Number
The Functional Group Control Number in
GS06 must be identical to data element
02 of the GE segment.
Must be ‘X’
1/9
The Functional Group Control Number in
GE02 must be identical to data element
06 of the GS segment.
6.2.2
9
The 271 Response
This section describes the values returned by CareFirst in the GS and GE segments.
IG Page
Reference
X12 Element
Name
Length
C.7
GS01
2/2
C.7
GS02
C.7
GS03
C.7
GS04
Functional Identifier
Code
Application
Sender’s Code
Application
Receiver's Code
Date
C.8
GS05
C.8
C.8
2/15
9
Valid Values/Notes/Comments
‘HB’- Eligibility Coverage or Benefit
Information
CareFirst ID
Trading Partner ID appended with ‘R’
8/8
CCYYMMDD
Time
4/8
HHMMSS
GS06
Group Control
Number
1/9
GS07
Responsible
Agency Code
1/2
The Functional Group Control Number in
GS06 must be identical to data element
02 of the GE segment.
‘X’
9
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
IG Page
Reference
C.8
GS08
C.9
GE01
C.9
GE02
6.3
X12 Element
Name
Version/ Release/
Industry Identifier
Code
Number of
Transaction Sets
Included
Group Control
Number
Length
Valid Values/Notes/Comments
1/12
“005010X279A1”.
1/6
‘1’
1/9
The Functional Group Control Number in
GE02 must be identical to data element
06 of the GS segment.
ST-SE
6.3.1
The 270 Eligibility/Benefit Inquiry
CareFirst requires standard HIPAA values in the ST and SE segments.
IG Page
Reference
X12 Element Name
Length
61
ST01
3/3
Must be “270”
61
ST02
4/9
62
ST03
The Transaction Set Control Numbers
in ST02 and SE02 must be identical.
Must be “005010X279A1”.
200
SE01
Transaction Set
Identifier Code
Transaction Set Control
Number
Implementation
Convention Reference
Number of Included
Segments
200
SE02
6.3.2
Transaction Set Control
Number
1/35
1/10
4/9
Valid Values/Notes/Comments
Count of data segments including ST
and SE Segments. In the event when
this count does not match the exact
number of data segments, a 997 is
generated.
The Transaction Set Control Numbers
in ST02 and SE02 must be identical.
The 271 Response
CareFirst returns standard HIPAA values in the ST and SE segments.
10
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
7.
CareFirst Business Rules and Limitations
7.1
Real Time Processing Mode
CareFirst supports only real time 270 inquiry and 271 response transactions.
7.2
Single Patient Inquiry
A real time transaction is limited to one patient per inquiry.
7.3
EQ segment
CareFirst supports an inquiry at the Service Type Level (EQ01). CareFirst does not recommend
inquiry at the Procedure Code level (EQ02). In an event when an inquiry at the Procedure Code
or Procedure/ Diagnosis Code Level is received, CareFirst will return a Baseline Service Type 30
Response.
Only the first EQ segment is processed for a response if multiple EQ Segments are received
within the 270 inquiry or to a single inquiry when there are multiple occurrences of EQ01.
In the examples below only Service Type Code ‘98’ will be processed.
Inquiry including Multiple EQ segments;
EQ✽98~
EQ✽34~
EQ✽44~
EQ✽81~
EQ✽A0~
EQ✽A3~
OR
Inquiry including a Single EQ segment with Repetition Function;
EQ✽98^34^44^81^A0^A3~
7.4
DTP segment
The criteria for Dates of Service are as follows;
1. Date has to be within the last calendar year.
2. It cannot surpass the end of the current month.
3. If a date range is received, the ‘From date’ will be used for processing and the ‘To
date’ will be ignored.
7.5
Error Conditions
1. A TA1 acknowledgement is returned when there is a transmission or envelope error (other
than a timeout).
2. A 999 acknowledgement is returned when there is a HIPAA or an X12 compliance error. The
Trading Partner should correct the error and resubmit the 270 transaction.
3. A 271 with an AAA segment is returned when there is a data error or when the system is
unavailable. The Trading Partner should correct the error and resubmit the 270 transaction.
11
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
4. Error conditions found on the 270 request that shall generate a 271 response containing an
AAA Segment with error codes are listed on the following table. Note the list is not limited to
AAA error codes generated locally, but also include AAA codes that may be returned by
another Blue Plan. Please refer to the table on Page 29 for CareFirst specific codes.
AAA Message Table (below)
Condition
AAA01 Code and
Meaning
Membership number is
not on file (subscriber
request)
N – No
Membership number is
not on file (dependent
request)
N – No
64 – Invalid Patient ID
C – Please correct and
resubmit
Missing patient date of
birth
N – No
58 - Invalid/Missing Date of
Birth
C – Please correct and
resubmit
Patient Date of birth
does not match that for
the Patient on the
database
N – No
71 - Birth date does not
match file
C – Please correct and
resubmit
System down
Y – Yes
42- Unable to respond at
this time (system down)
R – Resubmission allowed
Provider is ineligible
N – No
50 – Provider Ineligible
C – Please correct and
resubmit
Date of Service is not
within the last calendar
year or surpasses the
end of the current month
Y – Yes
62 – Date not within
allowable period
C – Please correct and
resubmit
Missing Subscriber
Name or Subscriber
name is not a match
Y – Yes
73 -Invalid/Missing
Subscriber/Insured name
C – Please correct and
resubmit
Missing Patient Name or
Patient name is not a
match
Y – Yes
65 – Invalid / Missing
Patient / Insured Name
C – Please correct and
resubmit
Missing Gender
Y – Yes
66 – Invalid/ Missing
Gender
C – Please correct and
resubmit
80- No Response Received;
Transaction Terminated
R – Resubmission allowed
72 – Invalid Subscriber ID
N – No
N – No
N – No
Batch/ Real Time Mode
Conflict
AAA03 Reason Reject
Code and Meaning
Y – Yes
AAA04 Follow up Action
Code and Meaning
C – Please correct and
resubmit
12
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
8.
Acknowledgements and/or Reports
The submitter of a 270 in real-time will receive only one acknowledgement/response from CareFirst: a
TA1 (error); a 999 (error); or a 271.
The TA1 Interchange Acknowledgement is used to indicate a rejection (aka a negative
acknowledgement) of the ISA/IEA Interchange containing the 270 Eligibility Benefit Inquiry Request.
If the 270 passes ISA/IEA compliance checking, but an error is found during the validation of the
Functional Group(s) or Transaction Set(s) within a Functional Group, a 999 Functional Acknowledgement
indicates a rejection (negative acknowledgement). If there are no errors a 999 is not returned.
If the 270 complies with the X12 standard syntax requirements, then the 271 Eligibility Inquiry Response
is returned to the submitter.
The AAA segments in the 271 are used to report business level error situations.
8.1
Report Inventory
There are no reports regarding the 270/271 transactions available to trading partners.
13
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
9.
Trading Partner Agreements
9.1
Trading Partners
All inquiries and comments regarding trading partner relationships with CareFirst should be
addressed by contacting CareFirst using the information in Section 5.
14
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
10. Transaction Information
10.1
The 270 Eligibility/Benefit Inquiry
This section describes the standard HIPAA values required by CareFirst in the BHT segment.
IG Page
Reference
X12 Element Name
Length
Valid
Values/Notes/Comments
63
BHT01
Hierarchical Structure
Code
4
Must be “0022”
64
BHT02
2
Must be “13”
64
BHT03
Transaction Set
Purpose Code
Reference
Identification
64
BHT04
Date
8/8
65
BHT05
Time
4/8
1/50
This identifier will be returned
in the corresponding 271
transaction’s BHT03.
CCYYMMDD
HHMM or HHMMSS or
HHMMSSD or HHMMSSDD
If BHT06 element is received, 270 will process without this element. CareFirst 270/271do not
support Medicaid Programs.
This section describes the values required by CareFirst in the HL segments.
IG
Page
Loop ID
Reference
67
2000A
HL01
67
2000A
HL02
67
2000A
HL03
68
2000A
HL04
73
2000B
HL01
73
2000B
HL02
74
2000B
HL03
74
2000B
HL04
88
2000C
HL01
X12 Element
Name
Hierarchical ID
number
Hierarchical
Parent ID
number
Hierarchical
Level Code
Hierarchical
Child Code
Codes
Length
Valid Values/Notes/Comments
Must be “1”
1/12
Initial HL Segment
Must be
missing
Must be
“20”
Must be “1”
1/2
Information Source
1/1
Hierarchical ID
number
Must be “2”
1/12
Additional Subordinate HL Data
Segment in this Hierarchical
Structure.
This number is incremented by one
for
each successive occurrence of the
HL segment.
Hierarchical
Parent ID
number
Hierarchical
Level Code
Hierarchical
Child Code
Must be “1”
Hierarchical ID
number
Must be
“21”
Must be “1”
1/2
Information Receiver
1/1
Must be “3”
1/12
Additional Subordinate HL Data
Segment in this Hierarchical
Structure.
This number is incremented by one
for
15
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
IG
Page
Loop ID
Reference
X12 Element
Name
Codes
Length
Valid Values/Notes/Comments
each successive occurrence of the
HL segment.
88
2000C
HL02
89
2000C
HL03
89
2000C
HL04
147
2000D
HL01
148
2000D
HL02
148
2000D
HL03
148
2000D
HL04
Hierarchical
Parent ID
number
Hierarchical
Level Code
Hierarchical
Child Code
Must be “2”
Must be
“22”
Must be “1”
OR “0”
1/2
Subscriber
1/1
Hierarchical ID
number
Must be “4”
1/12
Must be “1” when patient is
dependent; “0” when subscriber is
the patient.
This loop must be used only when
the patient is a dependent of a
Member.
Hierarchical
Parent ID
number
Hierarchical
Level Code
Hierarchical
Child Code
Must be “3”
1/12
Must be
“23”
Must be “0”
1/2
Dependent
1/1
This section describes the values required by CareFirst in the NM1 segments.
IG
Page
Loop ID
Reference
X12 Element Name
69
70
70
2100A
2100A
2100A
NM101
NM102
NM103
Entity Identifier Code
Entity Type Qualifier
Last Name or
Organization Name
71
2100A
NM108
71
2100A
NM109
Identification Code
Qualifier
Information Source
Primary Identifier
75
2100B
NM101
Entity Identifier Code
76
2100B
NM102
Entity Type Qualifier
77
2100B
NM108
Identification Code
Qualifier
78
2100B
NM109
Information Receiver
Primary Identifier
92
2100C
NM101
Entity Identifier Code
93
2100C
NM102
Entity Type Qualifier
Codes
Length
Must be “PR”
Must be “2”
Must be
“CareFirst
BlueCross
BlueShield”
Must be “PI”
2
1
1/60
Valid Values/Notes/Comments
Payor
Non-Person Entity
2
6
BCBS Plan Code
“080” or “190”
Must be
“1P”
Must be “2”
2
CareFirst will accept any of the
allowable values listed above.
Provider
Must be “XX”
2
National Provider Identifier
2/80
Must be provider’s National
Provider ID.
Must be
“IL”
Must be “1”
2
Insured or Subscriber
16
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
IG
Page
Loop ID
Reference
93
2100C
NM103
93
2100C
94
X12 Element Name
Codes
Length
Valid Values/Notes/Comments
Last Name
1/60
NM104
First Name
1/35
2100C
NM105
Middle Name
1/25
Required only when subscriber is
the patient.
Required only when subscriber is
the patient.
Submit if available for a subscriber.
95
2100C
NM108
96
2100C
NM109
Identification Code
Qualifier
Subscriber Primary
Identifier
Must be “MI”
2
3/17
Member Identification Number
CareFirst Member/Subscriber ID;
including 1-3 Character
Alphanumeric Prefix shown on ID
Card
Two ways that IDs can be sent:
1) ABC123456789
2) 123456789
A valid format for FEP membership
is R followed by 8 numeric
characters. Example: R12345678
114
2100D
NM101
Entity Identifier Code
Must be “03”
2
115
115
2100D
2100D
NM102
NM103
Entity Type Qualifier
Last Name
Must be “1”
115
2100D
NM104
First Name
1/35
115
2100D
NM105
Middle Name
1/25
1/60
Member ID suffix must not be
submitted.
Dependent
Person
Required when dependent is the
patient
Required when dependent is the
patient
Submit if available for a dependent.
This section describes the values recommended by CareFirst in the REF segment of the 2100B Information Receiver Name
Loop. This segment may be submitted at sender’s discretion but is not required.
IG Page
Loop ID
Reference
X12 Element Name
Codes
Length
79
2100B
REF01
Reference
Identification
Qualifier
Must be
“TJ”
2
80
2100B
REF02
Reference
Identification
1/30
Valid Values/Notes/Comments
Federal Taxpayer Identification
Number
Must be “Federal Taxpayer’s ID”
This section describes the values required by CareFirst in the TRN segment. TRN Segment may appear only at the subscriber
or dependent level. CareFirst strongly suggests the use of Transaction Trace Number (TRN) segments on ANSI 270
transactions. These TRN segments will be echoed on the ANSI 271 response.
17
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
IG Page
Loop ID
Reference
X12 Element
Name
Codes
Length
Valid Values/Notes/Comments
90
&
149
2000C
or
2000D
TRN01
Trace Type Code
Must be
“1”
1/2
Current Transaction Trace Number.
1. TRN segment in 2000C loop
may be assigned if the
subscriber is the patient.
2. TRN segment in 2000D loop
may be assigned if the
Dependent is the patient.
3. TRN segment will be moved
from 2100C to 2100D if
requested subscriber on 270 is
returned as the dependent in
the 271 response and vice
versa.
91
&
150
2000C
or
2000D
TRN02
Reference
Identification
1/50
91
&
150
2000C
or
2000D
TRN03
Originating
Company Identifier
10/10
This section describes the values required by CareFirst in the DMG segment. DMG Segment may appear only at the
subscriber or dependent level.
IG Page
Loop ID
Reference
108
&
165
108
&165
2100C or
2100D
DMG01
2100C or
2100D
109
&166
2100C or
2100D
X12 Element Name
Codes
Length
Valid Values/Notes/Comments
Date Time Period
Format Qualifier
Must be
“D8”
2/3
Date expressed in CCYYMMDD
DMG02
Date Time Period
CCYYM
MDD
1/35
Patient Date of Birth
1. In an event that DMG segment is not
received then AAA Error Code may
be generated.
2. In an event when a unique match is
not identified with the submitted date
of birth, AAA Error will be generated.
DMG03
Gender
F or M
1/1
1. Gender is optional on the 270 but
recommended for better eligibility
match.
2. Any other value other than F or M
submitted on 270 will generate a
999.
3. Patient gender will always be
returned on the 271.
This section describes the values required by CareFirst in the DTP segment. DTP Segment may appear only at the subscriber
or dependent level.
IG Page
Loop ID
Reference
123
&
179
2100C or
2100D
DTP01
X12 Element Name
Date/Time Qualifier
Codes
Length
Must be
“291”
3
Valid Values/Notes/Comments
Plan
18
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
IG Page
Loop ID
Reference
X12 Element Name
123 &
180
2100C or
2100D
DTP02
Date Time Period
Format Qualifier
123 &
180
2100C or
2100D
DTP03
Date Time Period
Codes
Length
Must be
D8 or
RD8
3
35
Valid Values/Notes/Comments
Date expressed in CCYYMMDD.
When “RD8” is sent as a qualifier
CareFirst will use the From Date as
DOS to search for eligibility. The
Through Date is ignored.
1. If this element is missing, then
current date is used as DOS to
search for eligibility.
2. When “RD8” is sent, DTP03
must be a date range.
3. In the event when “RD8” is sent
as a qualifier and a single date
is reported on DTP03, a 999 is
generated.
The 271 Response
The following describes the CareFirst utilization of segments and elements when there is some type of uniqueness or
restriction. All other values comply with HIPAA regulations.
This section describes the values returned by CareFirst in the NM1segments.
IG Page
Loop ID
Reference
218
219
219
220
2100A
2100A
2100A
2100A
NM101
NM102
NM103
NM108
220
2100A
NM109
X12 Element Name
Entity Identifier Code
Entity Type Qualifier
Entity Description
Identification Code
Qualifier
Information Source
Primary Identifier
232
2100B
NM101
Entity Identifier Code
234
2100B
NM108
Identification Code
Qualifier
235
2100B
NM109
Information Receiver
Primary Identifier
Codes
Length
“PR”
“2”
2
1
30
2
“PI”
“1P”
(provider)
or
“80”
(hospital)
or
“FA”
(facility) or
“GP”
(gateway
provider)
“XX”
Valid Values/Notes/Comments
Payor
“CareFirst BlueCross BlueShield”
6
“080” or “190”
2
CareFirst will respond on the 271
response with the same Plan Code
received on the 270 request.
From the 270
2
2/80
Health Care Financing Administration
National Provider Identifier
Provider’s National Provider Id
From the 270
19
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
251
2100C
NM108
Identification Code
Qualifier
“MI”
2
Member Identification Number
This section describes the values returned by CareFirst in the REF segment.
IG Page
Loop ID
Reference
237
2100B
REF01
237
2100B
REF02
254 and
358
2100C/2
100D
REF01
254 and
360
2100C/2
100D
REF02
Reference
Identification
254 and
358
2100C/2
100D
REF01
254 and
360
255 and
358
2100C/2
100D
2100C/2
100D
REF02
Reference
Identification
Qualifier
Reference
Identification
Reference
Identification
Qualifier
256 and
360
2100C/2
100D
REF02
REF01
X12 Element
Name
Reference
Identification
Qualifier
Reference
Identification
Reference
Identification
Qualifier
Reference
Identification
Codes
Length
“TJ”
2/3
Reference Identification Qualifier
1/50
Federal Taxpayer’s Identification
Number
Plan Number
“18”
2/3
1/50
“6P”
2/3
Valid Values/Notes/Comments
One of the following:
080 – National Capitol Area (DC)
190 – Maryland
FEP – Federal Employee
Program
OOA – Out of Area
TZF– Facets
580 –DC NASCO
690 – Maryland NASCO
Group Number
1/50
“EJ”
2/3
Patient Account Number
1/50
CareFirst will return the REF Segment
at the Subscriber level if 270 request
contained a REF segment with a
Patient Account Number.
If the 270 request specifies a particular service type in EQ01 (Service Type Code), the eligibility and benefit
information in the 271 EB Segment(s) returned pertain to that service type. A response to a service type can
contain references to multiple services covered/coinsured by CareFirst that pertain to the requested service type.
If the 270 request specifies a service type of “60” (General Benefits) in EQ01 (Service Type Code), only patient
demographic and active/inactive medical status is returned in the EB Segment.
If the 270 request specifies a service type of “30” (Health Benefit Plan Coverage) in EQ01 or if the service type
requested is not supported, the following information is returned on the EB Segment(s):
1. The patient’s eligibility status for service types that are covered.
2. The Co-pay, coinsurance and base contract deductible amounts (in and out of network) for the covered
services.
20
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
If the 270 request specifies a certain service code with specific procedure code, CareFirst will quote the benefit for
the service level code.
There can be multiple MSG segments in every response.
There can be multiple EB segments. This section lists Deductible—Accumulated, Out-of-pocket Maximums—
Static/Accumulated, Benefit Limitations—Accumulated information returned by CareFirst in the EB segment.
21
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
Deductible Name
Description
EB01
Eligibility Info
EB02
Coverage
Level
EB03 Service
Type
EB06
Time Qualifier
EB07
Amt
EB12
In-Network
Indicator
In network:
Individual
Yearly static value
dollar amount that
the patient owes
as an individual
deductible
C (Deductible)
IND
(Individual)
30
(Health Benefit
Plan Coverage)
Will be populated
with the value that
applies to the
deductible
present
Y
Dollar amount
remaining in order
for the individual
deductible to be
satisfied.
C (Deductible)
IND
(Individual)
30
(Health Benefit
Plan Coverage)
29
(Remaining)
present
Y
Yearly static value
dollar amount that
the patient owes
as an individual
deductible
C (Deductible)
IND
(Individual)
30
(Health Benefit
Plan Coverage)
Will be populated
with the value that
applies to the
deductible
present
N
Dollar amount
remaining in order
for the individual
deductible to be
satisfied.
C (Deductible)
IND
(Individual)
30
(Health Benefit
Plan Coverage)
29
(Remaining)
present
N
Yearly static
value dollar
amount that the
patient owes as a
family deductible
(if applicable)
C (Deductible)
FAM
(Family)
30
(Health Benefit
Plan
Coverage)
Will be populated
with the value
that applies to
the deductible
present
Y
Out of network:
Individual
In network:
Family
22
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
Out of network:
Family
Dollar amount
remaining in
order for the
family deductible
to be satisfied.
C (Deductible)
FAM
(Family)
30
(Health Benefit
Plan
Coverage)
29
(Remaining)
present
Y
Yearly static value
dollar amount that
the patient owes
as a family
deductible (if
applicable)
C (Deductible)
FAM
(Family)
30
(Health Benefit
Plan Coverage)
Will be populated
with the value that
applies to the
deductible
present
N
Dollar amount
remaining in
order for the
family deductible
to be satisfied.
C (Deductible)
FAM
(Family)
30
(Health Benefit
Plan
Coverage)
29
(Remaining)
present
N
23
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
EB02
EB03
EB06
EB07
EB12
C
IND and FAM
30 Health Benefit
Plan Coverage
Deductible Period
Code (for static)
Deductible
Amount
Y (in network) and N (out of network),
or Omit as applicable
C
IND and FAM
30 Health Benefit
Plan Coverage
29 (for
remaining)
Remaining
Deductible
Amount
Y (in network) and N (out of network),
or Omit as applicable
Description
EB01
Eligibility Info
EB02
Coverage Level
EB03 Service
Type
EB06
Time Qualifier
EB07
Amount
EB12
In-Network Indicator
Yearly static value
dollar amount that
represents the
individual out-ofpocket maximum.
G (Out of Pocket)
IND
(Individual)
30
(Health Benefit
Plan Coverage)
Will be populated with the period
value that applies to the out-ofpocket maximum
present
Y
Dollar amount
remaining in order for
the individual out-ofpocket maximum to
be satisfied.
G (Out of Pocket)
IND
(Individual)
30
(Health Benefit
Plan Coverage)
29
present
Y
Yearly static value
dollar amount that
represents the
individual out-ofpocket maximum.
G (Out of Pocket)
IND
(Individual)
30
(Health Benefit
Plan Coverage)
Will be populated with the period
value that applies to the out-ofpocket maximum
present
N
Dollar amount
remaining in order for
the individual out-ofpocket maximum to
be satisfied.
G (Out of Pocket)
IND
(Individual)
30
(Health Benefit
Plan Coverage)
29
present
N
Yearly static value
dollar amount that
represents the family
out-of-pocket
maximum.
G (Out of Pocket)
FAM
(Family)
30
(Health Benefit
Plan Coverage)
Will be populated with the period
value that applies to the out-ofpocket maximum
present
Y
24
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
Dollar amount
remaining in order for
the family out-ofpocket maximum to
be satisfied.
G (Out of Pocket)
FAM
(Family)
30
(Health Benefit
Plan Coverage)
29
present
Y
Yearly static value
dollar amount that
the patient owes as a
family deductible (if
applicable)
G (Out of Pocket)
FAM
(Family)
30
(Health Benefit
Plan Coverage)
Will be populated with the period
value that applies to the out-ofpocket maximum
present
N
Dollar amount
remaining in order for
the family deductible
to be satisfied.
G (Out of Pocket)
FAM
(Family)
30
(Health Benefit
Plan Coverage)
29
present
N
Out of Pocket segments will be formatted using these data elements:
EB01, EB02, EB03, EB06, EB07, EB12
The following segments and data elements will be used to format static and remaining out-of-pocket data:
G
IND and FAM
30 Health Benefit
Plan Coverage
Out of Pocket
Period Code (for
static)
Out of Pocket
Maximum
Amount
Y (in network) and N (out of network),
or Omit as applicable
G
IND and FAM
30 Health Benefit
Plan Coverage
29 (for
remaining)
Remaining Out of
Pocket Maximum
Y (in network) and N (out of network),
or Omit as applicable
Plans will also return appropriate HSD segments as applicable to the benefit design. HSD01–HSD08 show detailed benefit limit usage patterns.
HSD01
HSD02
HSD03
HSD04
HSD05
HSD06
HSD07
HSD08
Quantity
Qualifier
Quantity
Unit or basis for
measurement code
Quantity
Time Period
Number of periods
Delivery of
Calendar Pattern
Code
Time Period
25
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
This section describes the values returned by CareFirst in the INS segment.
IG Page
Loop ID
Reference
271
&
376
272
&
376
2100Cor
2100D
INS01
2100Cor
2100D
272
&
376
272
&
377
X12 Element
Name
Codes
Length
Valid Values/Notes/Comments
Yes/No
condition or
reason code
“Y” OR “N”
1/1
A “Y” value indicates the insured
is a subscriber: an “N” value indicates the insured
is a dependent.
INS02
Individual
Relationship
code
18, 01,19,20,
21,39, 40, 53,
G8
2/2
18 Self
01 Spouse
19 Child
20 Employee
21 Unknown
39 Organ Donor
40 Cadaver Donor
53 Life Partner
G8 Other Relationship
2100Cor
2100D
INS03
Maintenance
Type code
“001”
3/3
2100Cor
2100D
INS04
Maintenance
Reason code
“25”
2/3
Change.
CareFirst will return this element (and code “25" in
INS04) if any of the identifying
elements for the subscriber have been changed
from those
submitted in the 270.
Change in Identifying Data Elements.
CareFirst will return this element (and code “001" in
INS03) if any of the identifying
elements for the subscriber have been changed
from those
submitted in the 270.
26
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
11. Appendices
Appendix A
Implementation Checklist
CareFirst has four Preferred Trading Partners – RealMed, Siemens(HDX), Allscripts (Meddata) and Emdeon for
the 270/271 Eligibility Transaction. Please contact one of our preferred vendors to submit 270 transaction to
CareFirst.
Appendix B
271 AAA Error Codes
CareFirst 271 AAA Error Codes
This is the list of codes that will be returned for CareFirst local members. Please refer to Table 1. AAA Message Table
under Section 6.4 Error Conditions of this Companion Guide for conditions when each may be generated.
Error Codes
42
43
50
57
58
60
62
64
65
66
67
71
72
73
74
75
80
Description
unable to respond at this time (system down)
invalid provider id
provider ineligible
invalid date of service
invalid birth date
birth date after date of service
date not within allowable period
invalid patient id
invalid patient name
invalid gender
patient not found
birth date does not match file
invalid subscriber id
invalid subscriber name
invalid subscriber gender
subscriber not found
no response received
HIPAA 271 AAA Error Codes
The list below includes all HIPAA allowable AAA Error codes. The list below includes all HIPAA allowable AAA error codes
and returned from other Blues Plans when the member is out of area or Nasco. CareFirst will forward a 271 response
containing these AAA Error code to the Trading Partner without altering the response as per BCBSA rules:
Error Codes & Descriptions
04 too many patient requests
15 missing data
61
62
death precedes date of service
date not within allowable period
27
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
60
not authorized
unable to respond at this time (system down)
invalid provider id
invalid provider name
invalid provider specialty
invalid provider phone #
invalid provider state
invalid referring provider id
invalid primary care provider
provider ineligible
provider not on file
invalid service dates
invalid benefit type
invalid product id qualifier
invalid product id
invalid date
invalid date of service
invalid birth date
birth date after date of service
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
97
T4
invalid patient id
invalid patient name
invalid gender
patient not found
duplicate patient id number
inconsistent with patient's age
inconsistent with patient's gender
birth date does not match file
invalid subscriber id
invalid subscriber name
invalid subscriber gender
subscriber not found
duplicate subscriber number
patient not found
subscriber not in group
information source invalid
no response received
invalid provider address
payer name missing
28
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
Appendix C
CareFirst Supported Service Types
270
271
Provider Requests
Provider Receives
(at minimum)
EQ01 Service Type
Request
1 Medical Care
EB03 Service Type(s)
Response
1 Medical Care***
2 Surgical
42 Home Health Care
45 Hospice
69 Maternity
76 Dialysis
83 Infertility
AG Skilled Nursing Care
BT Gynecological
BU Obstetrical
DM Durable Medical Equipment***
Liability
Summary
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
***For these codes,
CareFirst returns
Active/Non-Covered only.
2 Surgical
2 Surgical
7 Anesthesia
8 Surgical Assistance
20 Second Surgical Opinion
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
4 Diagnostic X-Ray
4 Diagnostic X-Ray
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
29
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
5 Diagnostic Lab
5 Diagnostic Lab
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
6 Radiation Therapy
6 Radiation Therapy
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
7 Anesthesia
7 Anesthesia
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
8 Surgical Assistance
8 Surgical Assistance
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
12 Durable Medical
Equipment Purchase
12 Durable Medical Equipment
Purchase
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
13 Ambulatory Service
Center Facility
13 Ambulatory Service Center
Facility
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
30
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
18 Durable Medical
Equipment Rental
18 Durable Medical Equipment
Rental
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
20 Second Surgical Opinion
20 Second Surgical Opinion
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
30 Health Benefit Plan
Coverage
1 Medical Care***
33 Chiropractic
35 Dental Care****
47 Hospital
48 Hospital Inpatient
50 Hospital Outpatient
51 Hospital - Emergency Accident
52 Hospital - Emergency Medical
86 Emergency Services
88 Pharmacy****
98 Professional Visit Office:
Physician
98 Professional (Physician) Visit Office
MSG01="SPECIALIST"
AL Vision/Optometry****
BZ Professional Visit Office: Well
MH Mental Health***
UC Urgent Care
Co-insurance,
Deductible,
Co-pay,
Accumulated Benefits
Benefit Limits
Place of Service
33 Chiropractic
4 Diagnostic X-Ray
33 Chiropractic
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
35 Dental Care
35 Dental Care
Active/ Inactive
(at Minimum)
***For these codes we return
Active Only, we do not
return Liability. We omit if
non-covered
**** For these codes we
return Active at a minimum
and omit if non-covered
31
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
40 Oral Surgery
40 Oral Surgery
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
42 Home Health Care
42 Home Health Care
A3 Professional (Physician) Visit Home
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
45 Hospice
45 Hospice
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
47 Hospital
47 Hospital
51 Hospital - Emergency Accident
52 - Hospital - Emergency Medical
53 - Hospital - Ambulatory Surgical
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
48 Hospital - Inpatient
48 Hospital - Inpatient
99 Professional (Physician) Visit Inpatient
Co-insurance, Deductible,
Co-pay, Benefit Limits,
Place of service
Accumulated Benefits
50 Hospital - Outpatient
50 Hospital Outpatient
51 Hospital - Emergency Accident
52 Hospital - Emergency Medical
A0 Professional (Physician) Visit Outpatient
Co-insurance, Deductible,
Co-pay, Benefit Limits,
Place of service,
Accumulated Benefits
32
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
51 Hospital - Emergency
Accident
51 Hospital - Emergency Accident
Co-insurance, Deductible,
Co-pay, Benefit Limits,
Place of service
Accumulated Benefits
52 Hospital - Emergency
Medical
52 Hospital - Emergency Medical
Co-insurance, Deductible,
Co-pay, Benefit Limits,
Place of service
Accumulated Benefits
53 Hospital - Ambulatory
Surgical
53 Hospital - Ambulatory Surgical
Co-insurance, Deductible,
Co-pay, Benefit Limits,
Place of service
Accumulated Benefits
60 General Benefits
60 General Benefits
Active/Non-Covered only
61 In-vitro Fertilization
61 In-vitro Fertilization
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
62 MRI/CAT Scan
62 MRI/CAT Scan
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
65 Newborn Care
65 Newborn Care
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
68 Well Baby Care
68 Well Baby Care
80 - Immunizations
BH - Pediatric
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
33
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
69 Maternity
69 Maternity
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
73 Diagnostic Medical
73 Diagnostic Medical
4 Diagnostic X-Ray
5 Diagnostic Lab
62 MRI/CAT Scan
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
76 Dialysis
76 Dialysis
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
78 Chemotherapy
78 Chemotherapy
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
80 Immunizations
80 Immunizations
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
81 Routine Physical
81 Routine Physical
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
82 Family Planning
82 Family Planning
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
34
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
83 Infertility
83 Infertility
61 In-vitro Fertilization
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
84 Abortion
84 Abortion
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
86 Emergency Services
86 Emergency Services
51 Hospital - Emergency Accident
52 Hospital - Emergency Medical
98 Professional (Physician) Visit Office
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
88 Pharmacy
88 Pharmacy
Active/ Inactive
(at Minimum)
93 Podiatry
93 Podiatry
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
98 Professional (Physician)
Visit - Office
98 - Professional (Physician) Visit
Office
BZ - Professional Visit Office: Well
98 - Professional (Physician) Visit Office with
MSG01 = 'SPECIALIST'
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
35
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
99 Professional (Physician)
Visit - Inpatient
99 Professional (Physician) Visit Inpatient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
A0 Professional (Physician)
Visit - Outpatient
A0 Professional (Physician) Visit Outpatient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
A3 Professional (Physician)
Visit - Home
A3 Professional (Physician) Visit Home
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
A6 Psychotherapy
A6 Psychotherapy***
*** For these codes, we
return Active/Non-Covered
at a minimum
A7 Psychiatric - Inpatient***
***For these codes, we
return Active/Non-Covered
at a minimum
A7 Psychiatric - Inpatient
A8 Psychiatric - Outpatient
A8 Psychiatric - Outpatient***
***For these codes, return
Active/Non-Covered at a
minimum
36
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
AD Occupational Therapy
AD Occupational Therapy
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
AE Physical Medicine
AE Physical Medicine
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service,
Accumulated Benefits
AF Speech Therapy
AF Speech Therapy
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
AG Skilled Nursing Care
AG Skilled Nursing Care
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
AI Substance Abuse
AI Substance Abuse
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
AL Vision (Optometry)
AL Vision (Optometry)
Active/ Inactive
(at Minimum)
37
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
BG Cardiac Rehabilitation
BG Cardiac Rehabilitation
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
BH Pediatric
BH Pediatric
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of service
Accumulated Benefits
BT Gynecological
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
BU Obstetrical
BU Obstetrical
BV
Obstetrical/Gynecological
BV Obstetrical/Gynecological***
BT Gynecological
BU Obstetrical
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
*** For this code, we only
return Active/Non-Covered
BY Physician Visit – Office:
Sick
BY Physician Visit – Office: Sick
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
BZ Physician Visit – Office:
Well
BZ Physician Visit – Office: Well
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
BT Gynecological
BT
Gynecological
38
CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
CE MH Provider – Inpatient
CE MH Provider – Inpatient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Benefit Limits,
Place of Service,
Accumulated Benefits
CF MH Provider – Outpatient
CF MH Provider – Outpatient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
CG MH Provider Facility –
Inpatient
CG MH Provider Facility – Inpatient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
CH MH Provider Facility –
Outpatient
CH MH Provider Facility –
Outpatient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
CI Substance Abuse Facility
– Inpatient
CI Substance Abuse Facility –
Inpatient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
CJ Substance Abuse
Facility – Outpatient
CJ Substance Abuse Facility –
Outpatient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
CK Screening X-ray
CK Screening X-ray
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
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CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
CL Screening Laboratory
CL Screening Laboratory
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
CM Mammogram, HR Patient
CM Mammogram, HR Patient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
CN Mammogram, LR Patient
CN Mammogram, LR Patient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
CO Flu Vaccination
CO Flu Vaccination
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulated Benefits
DM Durable Medical
Equipment
DM Durable Medical Equipment ***
12 Durable Medical Equipment
Purchase
18 Durable Medical Equipment
Rental
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulators
*** For this code, we only
return Active/Non-Covered
MH Mental Health
MH Mental Health***
CE MH Provider – Inpatient
CF MH Provider – Outpatient
CG MH Provider Facility – Inpatient
CH MH Provider Facility –
Outpatient
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulators
*** For this code, we only
return Active/Non-Covered
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CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
PT Physical Therapy
PT Physical Therapy
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service,
Accumulators
UC Urgent Care
UC Urgent Care
Co-insurance,
Deductible,
Co-pay,
Benefit Limits,
Place of Service
Accumulators
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CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
Appendix D
Acronyms and Definitions
The following is a list of key terms commonly associated with the Health Insurance Portability and Accountability
Act (HIPAA).
BOL
CMDB
DDE
EDI
FEP
HWS
IACS
NPI
XML
270
271
999
B2B Services Gateway
CARE
FEPOC
FLEXX
FACETS
FEP Thin
Nasco InterAct
HIPAA
Accredited Standards Committee (ACS)
Accredited Standards Committee X12 (ASC
X12)
Business Objects Layer
Common Member Data Base
Direct Data Entry
Electronic Data Interchange
Federal Employee Program
HIPAA Web Services
Inquiry, Analysis and Control System
National Provider Identification number
Extensible Markup Language
The patient eligibility request transaction.
The patient eligibility response transaction.
The X12 transaction to notify a Trading Partner
when there is a format problem with an
incoming (270) request.
Carefirst access point for electronic commerce.
Claims processing system used for MD claims.
Federal Employee Program Operations Center.
It is the central location where all FEP claims
must be sent in order to receive
responses/answers to claims that have been
billed/ processed by FEP adjudicators.
Claims processing system used for DC
Commercial and FEP claims.
Future claims processing system for commercial
business.
FCC (FEP Claims Centralization) It is the level
below the pipeline that contains touchpoints
(pricer, ODS, claimcheck, etc) for FEP
processing prior to sending those claims to the
FEPOC.
Future claims processing system for national
and Bluecard business
Health Insurance Portability Accountability Act
of 1996
ACS is an organization accredited by the
American National Standards Institute (ANSI)
for the development of American National
Standards.
ASC X12 is a group accredited by the American
National Standards Institute (ANSI) that defines
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CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
electronic data interchange (EDI) standards for
many American industries, including health care
insurance.
Accredited Standards Committee X12N (ASC
X12N)
ASC X12N is a subcommittee of X12 that
defines electronic data interchange (EDI)
standards for the insurance industry, including
health care insurance.
American National Standards Institute (ANSI)
ANSI is an organization that accredits various
standards-setting committees, and monitors
their compliance. HIPAA prescribes that,
whenever practical, ANSI-accredited bodies
develop mandated standards.
Implementation Guide (IG)
IGs are documents explaining the proper use of
a standard for a specific business purpose. The
X12N HIPAA IGs are the primary reference
documents used by those implementing the
associated transactions and are incorporated
into the HIPAA regulations by reference.
TA1
The X12 transaction to notify a Trading Partner
when there is an interchange problem.
A standard transmission protocol and data
format used for EDI transactions.
Extensible Markup Language
The subscriber level
The network which the provider participates in
(example POS or HMO)
Any restrictions, maximums of limitations on the
service type including but not limited to
maximum dollar per year, provider type to
perform service, number of hours service
allowed per day, age limits.
OOP is based upon the CareFirst payment to
100% where the plateau is based upon a
combination of member responsibility which
would mean deductible amounts and/or
coinsurance and/or co payments.
X12
XML
Contract Level
Network Level
Service Level
Out of Pocket
Static Deductible
Static Out of Pocket
Stop Loss
The deductible amount to be met every year as
stated in the Benefit Booklet
The Out of Pocket amount to be met every year
as stated in the Benefit Booklet
Stop Loss is based upon the CareFirst payment
changing to 100% where the plateau is based
upon the total of eligible expenses before
payment is calculated, but after the deductible is
subtracted.
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CareFirst HIPAA 270-271 Transaction and Code Sets Companion Guide
Appendix E
Change Summary
The following chart includes the summary of changes made to the Companion Guide.
Companion Document Change Summary
Date
Version
Status
12/18/12
Version 1.1
Addition
Page
Description
Updates have been made to incorporate the
CORE Companion Guide Template Rule
changes.
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