IHCEBI Interactive health insurance eligibility and benefits inquiry and

D11 Healthcare (SWG)

The IHCEBI message is sent from institutional or individual health care providers or those providing related administrative services to a funding institution to obtain health insurance information from a patient's health plan prior to or at the time of admission or treatment.

This inquiry message will allow a health care provider to give their patient an estimate of cost for certain treatments, or assess their own financial risk associated with certain treatments, and provide the patient with informed financial choices regarding their health care options.

Each inquiry can provide information to the health plan about a service being considered, (e.g., actual or expected service dates, actual or expected duration of hospital stay, and planned services). An inquiry can also contain information about the treating and referring practitioner, if they are not the health care party making the inquiry.

The response message will provide information regarding what benefits are available to the patient based on their health plan contract and the information provided with the inquiry. This can include financial information, such as, co-pay amounts, deductible amounts, limitations, and exclusions.

Each response can also provide information regarding administrative issues concerning a covered benefit, such as, indicate who is the primary provider for a service, contact information for the health plan and patient, and policy rules, such as, certain screening exams can only be done once every two years.

Header

1. 0010 · UIH · Interactive message header · Max 1 · Mandatory

   To head, identify and specify a message.

   1. The value in 0340 shall be unique within the interchange (except for a
   duplicate transfer).
   2. The value(s) in S302 shall be identical to the value(s) in S302 in the
   preceding UIB.
   3. 0035, when used, test applies to the message only.
   4. Dialogue control can be accomplished through the dialogue reference
   (S302). Optionally, if another means of control is chosen, this composite
   data element need not be utilised.
   5. A combination of 0340 and S302 may be used to identify uniquely a message.

2. 0020 · MSD · Message action details · Max 1 · Mandatory

   To specify the message and business function and to provide a tracking mechanism.

3. Segment group 1 Repeat 9

   1. 0040 · PRT · Party information · Max 1 · Mandatory

      To provide specific identification number and demographic information regarding the identity of the participating parties.

   2. 0050 · NAA · Name and address · Max 9 · Conditional

      To specify the name/address and their related function, either by E082 only and/or unstructured by E058 or structured by E080 through 3207.

   3. 0060 · CON · Contact information · Max 9 · Conditional

      To specify contact communication numbers and names.

   4. 0070 · FRM · Follow-up action · Max 9 · Conditional

      To identify a follow-up action that should occur.

4. Segment group 2 Repeat 1

   1. 0090 · DTI · Date and time information · Max 1 · Mandatory

      To specify dates and times, related text and time references.

   2. 0100 · ICI · Insurance cover information · Max 1 · Conditional

      To specify a type of insurance, if it is required, and the coverage, limit, and deductible amounts.

   3. 0110 · FRM · Follow-up action · Max 9 · Conditional

      To identify a follow-up action that should occur.

   4. Segment group 3 Repeat 999

      1. 0130 · BCD · Benefit and coverage detail · Max 1 · Mandatory

         A segment to identify and provide information about benefit and coverage.

      2. 0140 · HDS · Health diagnosis service and delivery · Max 9 · Conditional

         A segment to provide specific information about covered benefit services, which is used to report a diagnosis to show necessity, the service or procedure being requested or provided, and service delivery instructions.

      3. 0150 · DTI · Date and time information · Max 1 · Conditional

         To specify dates and times, related text and time references.

      4. 0160 · PRT · Party information · Max 9 · Conditional

         To provide specific identification number and demographic information regarding the identity of the participating parties.

      5. 0170 · FRM · Follow-up action · Max 9 · Conditional

         To identify a follow-up action that should occur.

5. 0180 · UIT · Interactive message trailer · Max 1 · Mandatory

   To end and check the completeness of a message.

   1. 0340, the value shall be identical to the value in 0340 in the
   corresponding UIH segment.