HIPAA Transaction Standard Companion Guide …...2018/04/09 · 270/271 transaction set in the electronic data interchange (EDI) environment. The 270 transaction is used to request

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HIPAA Transaction Standard Companion Guide 270/271 Health Care Eligibility Benefit

Inquiry and Response

VERSION: 1.8 DATE: 06/25/2019

UCare Minnesota v5010 ASC X12N (ASC X12N 005010X279A1) 270/271 Companion Guide


Disclosure Statement This document is intended to be a companion guide for use in conjunction with the ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides. This document contains clarifications as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Standard for Electronic Transactions. This document is not intended to convey information that exceeds the requirements or usages of data expressed in the ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides defined by HIPAA. UCare is committed to maintaining the integrity and security of health care data in accordance with applicable laws and regulations. This material contains confidential, propriety information. Unauthorized use or disclosure of the information is strictly prohibited. The information in the document is furnished for UCare and Trading Partner use only. Changes are periodically made to the information in this document, these changes in the product and/or program described in the publication at any time. Disclosure of beneficiary eligibility data is restricted under the provisions of the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Provider Beneficiary eligibility transaction is to be used for conducting UCare business only. Please note: The 271 response returned by the 270/271 application should not be interpreted as a guarantee of payment. Payment of benefits remains subject to all health benefit plan terms, limits, conditions, exclusions and the member’s eligibility at the time services are rendered.



Table of Contents

Chapter 1: Introduction

Scope 4

Overview 4

References 4

Additional Information 4

Chapter 2: Getting Started

Working with UCare 5

Trading Partner Registration 5

Certification and Testing Overview 5

Testing with Payer 5

Chapter 3: Connectivity with the payer/Communications

Process flow 6

Transmission Administrative Procedures 6

Re-Transmission Procedure 7

Communication protocol specifications 7

Passwords 7

Chapter 4: Contact Information

EDI Customer Service 8

EDI Technical Assistance 8

UCare Provider Service 8

Chapter 5: Control Segments/Envelopes

ISA-IEA 9

GS-GE 10

ST-SE 11

Chapter 6: Payer Specific Business Rules and imitations 12

Chapter 7: Acknowledgements and/or Reports 13

Chapter 8: Trading Partner Agreements 14

Chapter 9: Transaction Specific Information

270 Transaction Specific Information 15

271 Transaction Specific Information 16

Appendices 17



Chapter 1: Introduction

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 UCare. Transmissions based on this companion guide,

used in conjunction with the v5010 ASC X12N Implementation Guides and the Minnesota Uniform Companion 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 and Minnesota Uniform Companion 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.

Scope

This Companion Guide is intended to describe to UCare trading partners the content and format of the Eligibility and Benefit

270/271 transaction set in the electronic data interchange (EDI) environment. The 270 transaction is used to request

eligibility and benefit information for medical lines of business, and the 271 transaction is used to respond with information

for the specified member.

Overview

The purpose of this document is to provide information for conducting HIPAA compliant electronic 270/271 transaction

exchanges with UCare.

References

ASC X12 publishes implementation guides, known as Technical Reports Type 3 (TR3s), that define the data contents and

compliance requirements for the health care implementation of the ASC X12N/005010 transaction sets. Following are the

Interchange Technical Report Type 3 (TR3s) referenced in this guide:

ASC X12N/005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271) and

Associated errata, hereinafter 005010X279A1 TR3s.

You are expected to comply with the requirements set forth in the TR3s. You can purchase these guides from the ASC X12

store at http://store.x12.org/ or from Washington Publishing Company (http://www.wpc-edi.com).

Entities subject to Minnesota Statutes, section 62J.536 and related rules must follow the data content and other transaction-

specific information of the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X279A1

Health Care Eligibility Inquiry and Response (270/271). A copy of the Minnesota Uniform Companion Guide is available at no

charge from the Minnesota Department of Health at: http://www.health.state.mn.us/asa/rules.html

Additional Information

Both real-time and batch 270 inquiries are supported through this transaction.

This transaction supports inquiries for UCare members only.

Please note that for UCare members enrolled in Minnesota Health Care Programs (MHCP), MN-ITS, the Minnesota

Department of Human Services (DHS) direct data entry system, provides the most current eligibility information.

UCare will respond to inquiries for these members, but the response may not reflect the member’s current eligibility

state due to retroactivity and the timing of file exchanges between UCare and DHS. UCare recommends providers

use MN-ITS for eligibility verification for the MHCP population.

http://store.x12.org/

http://www.wpc-edi.com/

http://www.health.state.mn.us/asa/rules.html

https://mn-its.dhs.state.mn.us/



Chapter 2: Getting Started

Working with UCare

UCare offers the 270/271 EDI transaction through Change Healthcare (formally RelayHealth) Payer Connectivity Services

(PCS), clearinghouse. This guide includes the instructions you will need to establish connection with PCS to begin exchanging

standard 270/271 transactions.

Trading Partner Registration

Before submitting/receiving a 270/271 transaction, you and/or your clearinghouse must register as a trading partner with

PCS. This will require some technical effort on your part to be able to exchange real-time transactions. Please have your

clearinghouse contact PCS directly at:

CONTACT INFO: PCS Support

PHONE: 1-877-411-7271

EMAIL: [email protected]

Changes begin with PCS creating access credentials with your clearinghouse. The submitter ID and receiver ID (ISA06/08) used

for electronic claims submission will also be used as the submitter ID values for real-time eligibility transactions. Submitters

do have the ability to test the eligibility transactions.

Certification and Testing Overview

UCare recommends submitting at least one test file to ensure connectivity and data transfer is successful with PCS; however,

testing is not required. If you are interested in testing, you may contact PCS Support 1-877-411-7271 or

[email protected]. This companion guide will serve as an aid in completing the testing process.

Testing with the Payer/Communications

Testing can begin once the necessary provisioning is completed between the clearinghouse and PCS and connectivity

information is provided to the submitter.

mailto:[email protected]




Chapter 3: Connectivity with the Payer/Communications

System Availability and Downtime

PCS is generally available 24 hours a day, 7 days a week for 270/271 transaction exchange. To allow for periodic

maintenance, PCS will schedule downtime during which 270/271 transactions may be unavailable. PCS will send out

appropriate notification when downtime is scheduled.

CONTACT INFO: PCS Support PHONE: 1-877-411-7271 EMAIL: [email protected]

Process Flows

This section outlines the processes associated with submitting and receiving 270/271 transactions with UCare, via PCS.

Provider/Provider Clearinghouse

PCS (UCare’s contracted vendor)

Real-Time 270 Inquiry

TA1 or 999and/or 271 Response

Transmission Administrative Procedures

Real time 270 requests must contain a single member inquiry for each transaction. In addition, UCare only allows a single

transaction to be contained within a submission as follows:

One interchange (ISA-IEA) per transmission

One functional group (GS-GE) per transmission

One transaction set (ST-SE) per transmission

Batch 270 requests are limited to 99 ST/SE groupings per transaction. Each batch inquiry must be in its own ST/SE.

Re-Transmission Procedure

All X12 file submissions are pre-screened upon receipt to determine if the interchange control header (ISA) or interchange

control trailer (IEA) segments are readable. If errors are found, a TA1 response transaction will be sent to notify the trading

partner the file could not be processed.




If the transaction submission passes the ISA/IEA pre-screening above, it is then checked for ASC X12 syntax and HIPAA-

compliance errors. If there are errors found when the compliance check is complete, a 999 will be sent to the trading partner

informing them if the transaction has failed the compliance check. The following notifications will be sent if a transmission is

unable to be completed:

Acknowledgements Description

ASC X12 TA1 v005010X231A1 (HIPAA) Response to the X12 transactions where errors are encountered in the outer envelopes (ISA/IEA and GS/GE segments)

ASC X12 999 v005010X231A1 (HIPAA) Functional Acknowledgement: A negative 999 is sent in case of compliance issues.

To receive a 271 response, errors must be corrected and the 270 inquiry resent.

Communication Protocol Specifications

UCare, via PCS, has provided connectivity that complies with the Committee on Operating Rules for Information Exchange

(CORE) Safe Harbor principle (§5 Safe Harbor) according to the CORE Connectivity Phase II Rule 270. Submitters may contact

PCS for specification details.

Passwords

As a secure connection between PCS and UCare has already been established, any passwords to protect the security of the

data would need to be established between the trading partner and PCS. PCS requires each interchange submitter ID to be

accompanied with a unique password for security reasons.



Chapter 4: Contact Information

EDI Customer Service

For inquiries related to 270/271 transaction setup and testing, please contact PCS customer support directly:

Phone: 1-877-411-7271

Days/Times: Monday – Friday, 8:00 a.m. – 5:00 p.m. CST

Email: [email protected]

EDI Technical Assistance

Once provisioned by PCS and actively using the 270/271 transaction, you may contact PCS customer support directly for EDI

technical assistance:

Phone: 1-877-411-7271

Days/Times: Monday – Friday, 8:00 a.m. – 5:00 p.m. CST

Email: [email protected]

UCare Provider Service

If you require more details about eligibility beyond what was provided in your 271 response, please log into UCare’s provider

portal at www.ucare.org/providers.

Providers can also contact UCare’s Provider Assistance Center (PAC) for more detailed claim status information. Please note

that PAC representatives cannot assist with the interpretation of error reports received from PCS/their clearinghouse. These

questions must be directed to PCS as noted above.

Phone: 612-676-3300 or 1-888-531-1493 toll free

Days/Times: Monday - Friday, 8:00 a.m. – 5:00 p.m. CST

Email: Contracted providers may also contact UCare via secure email on the UCare Provider Portal.



http://www.ucare.org/providers



Chapter 5: Control Segments/Envelopes

ISA-IEA

This section describes the use of the Interchange Control segments (ISA, IEA). These segments mark the beginning

and ending of an interchange. This segment includes a description of the expected sender and receiver codes and

delimiters. The first element delimiter in the ISA segment is an Asterisk (*), which will be used as the delimiter

throughout the transaction. The final character in the ISA segment is a Tilde (~), which will be used as the delimiter

for each segment in the transaction.

270:

Segment ID

Element ID

Name Code Definition / Notes

ISA Interchange Control Header

ISA01 Authorization Information Qualifier ‘00’ No Authorization Information Present

ISA02 Authorization Information Authorization Information

ISA03 Security Information Qualifier ‘01’ Password Qualifier

ISA04 Security Information Password value

ISA05 Interchange ID Qualifier of Sender ‘ZZ’ Mutually defined

ISA06 Interchange Sender ID Interchange Sender ID

ISA07 Interchange ID Qualifier of Receiver ‘ZZ’ U.S. Federal Tax Identification Number

ISA08 Interchange Receiver ID UCARE Interchange Receiver ID for UCare

ISA09 Interchange Date YYMMDD Date of the interchange

ISA10 Interchange Time HHMM Time of the interchange

ISA11 Interchange Control Standards Identifier

‘^’ U.S. EDI Community of ASC X12, TDCC and UCS

ISA12 Interchange Control Version Number ‘00501’

ISA13 Interchange Control Number Must be identical to IEA02

ISA14 Acknowledgment Requested ‘0’ No acknowledgment requested

ISA15 Usage Indicator ‘P’ P: Production Data

ISA16 Component Element Separator : Component element separator is a delimiter and not a data element

IEA Interchange Control Trailer

IEA01 Number of Included Functional Groups

‘1’ Functional Group count

IEA02 Interchange Control Number Identical to ISA13

271:

Segment ID

Element ID


ISA Interchange Control Header

ISA01 Authorization Information Qualifier ‘00’ No Authorization Information Present

ISA02 Authorization Information Authorization Information

ISA03 Security Information Qualifier ‘00’ No Security Information Present

ISA04 Security Information No Security Information [Note: Value should always be ‘spaces’.]

ISA05 Interchange ID Qualifier of Sender ‘ZZ’ Mutually defined

ISA06 Interchange Sender ID UCARE Interchange Sender ID

ISA07 Interchange ID Qualifier of Receiver ‘ZZ’ U.S. Federal Tax Identification Number

ISA08 Interchange Receiver ID Interchange Receiver ID

ISA09 Interchange Date YYMMDD Date of the interchange

ISA10 Interchange Time HHMM Time of the interchange

ISA11 Interchange Control Standards Identifier

‘^’ U.S. EDI Community of ASC X12, TDCC and UCS

ISA12 Interchange Control Version Number ‘00501’

ISA13 Interchange Control Number Must be identical to IEA02

ISA14 Acknowledgment Requested ‘0’ No acknowledgment requested

ISA15 Usage Indicator ‘P’ P: Production Data

ISA16 Component Element Separator : Component element separator is a delimiter and not a data element

IEA Interchange Control Trailer

IEA01 Number of Included Functional Groups

‘1’ Functional Group count

IEA02 Interchange Control Number Identical to ISA13



GS-GE

This section describes the use of the Functional Group Control segments (GS, GE). This segment includes a

description of the expected sender and receiver codes and delimiters.

270:

Segment ID

Element ID


GS Functional Group Header

GS01 Functional Identifier Code ‘HS’ Eligibility, Coverage or Benefit Inquiry (270)

GS02 Application Sender’s Code Code identifying party sending transmission; codes agreed to by trading partners

GS03 Application Receiver’s Code UCARE Code identifying party receiving transmission; codes agreed to by trading partners

GS04 Interchange Date YYMMDD Date of the functional group creation

GS05 Interchange Time HHMM Time of the functional group creation

GS06 Group Control Number Identical to GE02

GS07 Responsible Agency Code ‘X’ Accredited Standards Committee X12. [Note: Value should always be ‘X’.]

GS08 Version / Release / Industry Identifier Code

‘005010X092A1’ Health Care Eligibility Benefit Inquiry and Response 270/271 Implementation Guide version

GE Functional Group Trailer

GE01 Number of Transaction Sets Included

‘1’ Transaction set count

GE02 Group Control Number Identical to GS06

271:

Segment ID

Element ID


GS Functional Group Header

GS01 Functional Identifier Code ‘HB’ Eligibility, Coverage or Benefit Information (271)

GS02 Application Sender’s Code UCARE Code identifying party sending transmission; codes agreed to by trading partners

GS03 Application Receiver’s Code Application Receiver Code

GS04 Interchange Date YYMMDD Date of the functional group creation

GS05 Interchange Time HHMM Time of the functional group creation

GS06 Group Control Number Identical to GE02

GS07 Responsible Agency Code ‘X’ Accredited Standards Committee X12. [Note: Value should always be ‘X’.]

GS08 Version / Release / Industry Identifier Code

‘005010X092A1’ Health Care Eligibility Benefit Inquiry and Response 270/271 Implementation Guide version

GE Functional Group Trailer

GE01 Number of Transaction Sets Included

‘1’ Transaction set count

GE02 Group Control Number Identical to GS06



ST-SE

This section describes the beginning and the ending of a transaction set and provides the count of the transmitted

segments including the beginning (ST) and ending (SE) segments.

270:

Segment ID

Element ID


ST Transaction Set Header

ST01 Transaction Set Identifier Code ‘270’ Eligibility, Coverage or Benefit Inquiry

ST02 Transaction Set Control Number 0001 Identical to SE02

SE Transaction Set Trailer

SE01 Transaction Segment Count <Total Segments> Total number of segments included in a transaction set including ST and SE segments.

SE02 Transaction Set Control Number 0001 Identical to ST02

271:

Segment ID

Element ID


ST Transaction Set Header

ST01 Transaction Set Identifier Code ‘271’ Eligibility, Coverage or Benefit Information

ST02 Transaction Set Control Number 0001 Identical to SE02

SE Transaction Set Trailer

SE01 Transaction Segment Count <Total Segments> Total number of segments included in a transaction set including ST and SE segments.

SE02 Transaction Set Control Number 0001 Identical to ST02



Chapter 6: Payer-Specific Business Rules and Limitations

This section describes UCare specific rules and limitations associated with the 270/271 transaction. It is important to review these as they may differ from rules and limitations required by other payers. UCare’s trading partners must adhere to the following business rules and limitations for submitting transactions in real time:

Only one transaction should be submitted per functional group.

Only one functional group should be submitted per interchange.

Member data should always be sent in the Subscriber Loop of the transaction (21xxC loops); UCare will not accept Dependent Loops (21xx D loops).

Search criteria used to identify a member includes: o Member ID, Date of Birth, and Last Name.

UCare strongly recommends always sending the member ID located on the member’s ID card. o If member ID is used: member ID and either last name or DOB are required.

o If member ID is not used: last name and DOB are required.

If no date of service is received, the current date will be considered as the date of service

When sending a 270 inquiry, using a specific Service Type Code related to the services being performed will provide

a more streamlined response. Service Type Codes that are not explicitly supported by UCare will return a response

equivalent to the Service Type Code 30 – Health Benefit Plan Coverage.

1-Medical Care 86-Emergency Services UC-Urgent Care

33-Chiropractic 88-Pharmacy

35-Dental Care 98-Professional (Physician) Visit-Office

47-Hospital AL-Vision (Optometry)

48-Hospital Inpatient MH-Mental Health

50-Hospital Outpatient

Future dates are supported and can be reported up to the last day of the current month.

Dates of service in the past are supported 12 months prior to the current date.

Procedure and/or diagnosis codes are not used to determine benefits.

Entities subject to Minnesota Statutes, section 62J.536 and related rules must follow the data content and other transaction specific information of the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X279A1 Health Care Eligibility Inquiry and Response (270/271). A copy of the Minnesota Uniform Companion Guide is available from the Minnesota Department of Health at no charge at: http://www.health.state.mn.us/asa/rules.html.




Chapter 7: Acknowledgement and/or Reports

UCare (PCS) processes the following ASCX12 HIPAA acknowledgements for Eligibility and Benefit Inquiries when there is an

issue with processing the 270 request.

‘AAA’ Error Codes

AAA03 Codes Required in Loop 2000A — INFORMATION SOURCE LEVEL

04 Authorized Quantity Exceeded

41 Authorization/Access Restrictions

42 Unable to Respond at Current Time

79 Invalid Participant Identification

AAA03 Codes Required in Loop 2100A — INFORMATION SOURCE NAME

04 Authorized Quantity Exceeded




80 No Response Received – Transaction Terminated

T4 Payer Name or Identifier Missing

AAA03 Codes Required in Loop 2100B — INFORMATION RECEIVER NAME

15 Required Application Data Missing


43 Invalid/Missing Provider Identification

44 Invalid/Missing Provider Name

45 Invalid/Missing Provider Specialty

46 Invalid/Missing Provider Phone Number

47 Invalid/Missing Provider State

48 Invalid/Missing Provider Referring Provider Identification Number

50 Provider Ineligible for Inquiries

51 Provider Not on File


97 Invalid or Missing Provider Address

T4 Payer Name or Identifier Missing

AAA03 Codes Required in Loop 2100C — SUBSCRIBER NAME

15 Required Application Data Missing

35 Out of Network


45 Invalid/Missing Provider Specialty

47 Invalid/Missing Provider State

48 Invalid/Missing Provider Referring Provider Identification Number

49 Provider is not a Primary Care Physician

50 Provider Ineligible for Inquiries

51 Provider Not on File

52 Service Dates Not Within Provider Plan Enrollment

56 Inappropriate Date

57 Invalid/Missing Date(s) of Service

58 Invalid/Missing Date of Birth

60 Date of Birth Follows Date(s) of Service

61 Date of Death Precedes Date(s) of Service

62 Date of Service Not Within Allowable Inquiry Period

63 Date of Service in Future

71 Patient Birth Date Does Not Match That for the Patient on the Database

72 Invalid/Missing Subscriber/Insured ID

73 Invalid/Missing Subscriber/Insured Name

74 Invalid/Missing Subscriber/Insured Gender Code

75 Subscriber/Insured Not Found

76 Duplicate Subscriber/Insured ID Number

78 Subscriber/Insured Not in Group/Plan Identified



Chapter 8: Trading Partner Agreements

Trading Partners

An EDI trading partner is defined as any UCare customer (provider, billing service, software vendor, employer group, financial

institution, etc.) that transmits electronic data to, or receives electronic data from UCare, or from a UCare contracted entity.

To ensure the integrity of the electronic transaction process, payers have EDI trading partner agreements that accompany the

standard implementation guide. The trading partner agreement is related to the electronic exchange of information, whether

the agreement is with an entity or part of a larger agreement. For example, a trading partner agreement may specify the

roles and responsibilities of each party to the agreement in conducting standard transactions.

As UCare will be directly exchanging 270/271 data with PCS, the existing trading partner agreement between UCare and PCS

will cover the data being passed and shared. It may be necessary for those originating these transactions to complete trading

partner agreements with PCS. Please refer to the Trading Partner Registration section in chapter 2 for additional direction

and contact information.



Chapter 9: Transaction Specific Information

A Transaction Loop is a group of related segments. UCare specific values are required for the elements that comprise the segments for the 270/271 Transaction Loops. The following section identifies these loops, their segments and their required element values. [Note: UCare does not support Dependent Loops: 2100D, 2110D, 2115D, and 2120D.] 270

Loop 2100A (270) Information Source

Loop Segment Element Name Code Definition / Notes

2100A NM1 NM101 Entity Identifier Code ‘PR’ Payer

2100A NM1 NM102 Entity Type Qualifier ‘2’ 2: Non-Person Entity

2100A NM1 NM103 Organization Name ‘UCARE’ Health Plan Name

2100A NM1 NM108 Identification Code Qualifier ‘PI’ PI: Payer Identifier

2100A NM1 NM109 Identification Code ‘UCARE’ UCare

Loop 2100B (270) Information Receiver


2100B NM1 NM101 Entity Identifier Code ‘1P’ Provider

2100B NM1 NM108 Identification Code Qualifier ‘34’ ‘FI’ ‘XX’

34: Social Security Number FI: Federal Taxpayer ID XX: NPI

2100B NM1 NM109 Identification Code of Provider requesting response

ID Code

Loop 2100C (270) Subscriber Information


2100C NM1 NM101 Entity Identifier Code ‘IL’ IL: Insured or subscriber

2100C NM1 NM102 Entity Type Qualifier ‘1’ 1: Person Entity

2100C NM1 NM103 Subscriber Last Name Member Last Name

2100C NM1 NM108 Identification Code Qualifier ‘MI’ Member Identification Code

2100C NM1 NM109 Subscriber Identification Code UCare Member ID

2100C DMG DMG01 Date Time Period Format Qualifier ‘D8’ D8: Format CCYYMMDD

2100C DMG DMG02 Subscriber Birth Date CCYYMMDD UCare Member Date of Birth

2100C DTP DTP01 Date/Time Qualifier ‘307’ 307: Eligibility

2100C DTP DTP02 Date/Time Period Format Qualifier ‘D8’

‘RD8’

D8: Date expressed in format CCYYMMDD; RD8: Range of Dates expressed in format CCYYMMDD-CCYYMMDD

2100C DTP DTP03 Date Time Period Range of dates is acceptable, but UCare only uses first date in range. If date is not provided, UCare will use current date.

Loop 2110C (270) Subscriber Eligibility & Benefit Information


2110C EQ UCare supports only one occurrence of the EQ segment per transaction

2110C EQ EQ01 Service Type Code ‘30’ (Generic)

Other standard codes available

Refer to section 7 for additional details.



271

Loop 2100A (271) Information Source


2100A NM1 NM101 Entity Identifier Code ‘PR’ Payer

2100A NM1 NM102 Entity Type Qualifier ‘2’ 2: Non-Person Entity

2100A NM1 NM108 Identification Code Qualifier ‘PI’ PI: Payer Identifier

2100A NM1 NM109 Identification Code ‘UCARE’ UCare

Loop 2100B (271) Information Receiver


2100B NM1 NM109 Identification Code Information on 270 transaction sent back on 271 transaction

Loop 2100C (271) Subscriber Information


2100C REF REF01 Group Number ‘6P’ Group Number

2100C REF REF02 Plan Number ‘18’ Plan Number

2100C DMG DMG02 Date of Birth Format CCYYMMDD

2100C DMG DMG03 Gender Code Gender Code

2100C N3 N301 Address Information Subscribers Address

2110C N3 N302 Address Information Use this information for the second line of the address information

2100C N4 N401 City Name Subscriber City Name

2100C N4 N402 State Subscriber State Code

2100C N4 N403 Postal Code Subscriber Postal Zone or ZIP Code

Loop 2110C (271) Subscriber Eligibility or Benefit Information


2110C EB EB01 Eligibility or Benefit Information

1 5 A B C F G I

1: Active Coverage 5: Active – Pending Investigation A: Co-Insurance B: Co-Payment C: Deductible F: Limitations G: Out of Pocket (Stop Loss) I: Non-Covered

2110C EB EB03 Service Type Code Explicit Service Type Code Response if requested

2110C EB EB05 Plan Coverage Description Plan Description, sent with Service Type Code ‘30’

2110C EB EB07 Monetary Amount Qualifier based on EB01. EB01=A, B, C, G

2110C DTP DTP01 Date/Time Qualifier ‘356’ ‘357’

356: Eligibility Begin Date 357: Eligibility End Date

2110C DTP DTP03 Date/Time Period Dates associated with DTP01 qualifier

2110C MSG MSG01 Free-Form Message Text Additional information as required

2110C MSG MSG02 Free-Form Message Text Additional information as required

The transaction-specific information for entities subject to Minnesota Statutes, section 62J.536 and related rules is incorporated by reference from the Minnesota Uniform Companion Guide (MUCG) for the ASCX12/005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) Version 6.0, at: http://www.health.state.mn.us/asa/rules.html. Readers are referred to the MUCG for information and instructions to comply with Minnesota’s requirements.




APPENDIX

Revision History

Revision Number

Date Section Notes

1.0 09/1/2016 Original document

1.1 12/5/2016 5. Contact Information Added references to information availability on UCare’s Provider Portal

1.2 11/7/2017 Disclosure Statement

1.3 01/1/2018 All Sections Updated all pages

1.4 04/9/2018 Change Healthcare name

1.5 06/30/2018 UCare log Subscriber N3-N4 Address

1.6 10/01/2018 Updated Logo

1.7 06/25/2019 Updated Change Healthcare email address

Documents

HIPAA Transaction Standard Companion Guide …...2018/04/09 · 270/271 transaction set in the electronic data interchange (EDI) environment. The 270 transaction is used to request