IHCLME Health care claim or encounter request and response

TBG10 Healthcare

This message is to support interactive submittal and response of health care claims or encounters for the point of sale environment. It will be used in health care information scenarios when immediate response is appropriate.

Header

1. 00010 · UIH · Interactive message header · Max 1 · Mandatory

   A service segment starting and uniquely identifying a message. The message type code for the Health care claim or encounter request and response - interactive message is IHCLME. Note: Health care claim or encounter request and response - interactive messages conforming to this document must contain the following data in segment UIH, composite S306: Data element 0065 IHCLME 0052 D 0054 12A 0051 UN

2. 00020 · MSD · Message action details · Max 1 · Conditional

   To specify the message processing requirements, response type, and to provide a tracking mechanism. The reference number in this segment will provide for a different tracking number than what is generated in the message envelope, for application level tracking.

3. 00030 · PRT · Party information · Max 9 · Conditional

   To provide specific identification numbers and demographic information regarding the identity of the participating parties. Date of birth, eligibility date, and date of death may be specified as well as relationship between the patient and the insured, sex, employment category, marital status, student status, and a yes or no indication of whether the patient is pregnant.

4. 00040 · NAA · Name and address · Max 9 · Conditional

   To specify a party identity, and, when necessary, the name and/or the address in either a structured or unstructured format. For use in health care, it is recommended to use only the identification, but if the name or address are needed, to use only the structured method of submittal.

5. 00050 · CON · Contact information · Max 9 · Conditional

   To provide electronic message routing information for additional recipients of this message. The reference number will provide a unique reference number to be used by the contact entity when referring to this message.

6. 00060 · BLI · Billable information · Max 1 · Conditional

   To provide summarized information about all services covered under one health care claim or encounter. This segment allows detail relating to monetary amounts for the total amount being charged for the claim, total amount that the patient has paid, and the total amount paid by other benefit carriers. Multiple diagnoses that apply to the entire claim, and multiple dates may be conveyed. The plan sponsor can receive the reference of any pre-authorization information associated with the claim and through a series of yes and no indications will know whether the provider accepts the insurance payment as payment in full, and whether the patient has signed documents releasing the medical information to the insurance carrier and authorizing the payment directly to the provider. The presence, nature, date, and state or province of a cause related to this claim, such as an accident, may also be indicated.

7. 00070 · ITC · Institutional claim · Max 1 · Conditional

   To provide specific claim information only needed when processing claims for services performed while admitted to a health care institution. When the claim is generated from a health care institution, additional information such as the type (e.g. first, intermediate, last) and frequency of invoicing during an extended admission, the number of days covered and non covered by insurance, the type (e.g. emergency, scheduled) and source of admission, the discharge type (e.g. ambulatory, transfer, dead), and information about other products and services related to the institutional admission may be needed.

8. 00080 · ADI · Health care claim adjudication information · Max 99 · Conditional

   To provide adjudication information for all services, supplies or products in the health care claim. The internal control number assigned by the payer, the specific service trace or sequence number designated for this service in the original claim, the payment or draft control number, the health care service being paid, the health case service originally billed, the health care service institutional "revenue" code, the notification of the adjudication action taken by the payer, the total amount paid, other informational amounts (e.g negotiated discount), the number of services adjudicated, the number of services originally billed, the importance given to the diagnosis related group in calculating the payment, the financial adjustments (e.g. deductible, agreed fee limit) made in the adjudication, identification of health care policy limitations, the insurance product group (e.g. indemnity, managed care, federal program), the anticipated date of payment, the diagnosis category from a diagnosis related grouping program, and the percentage known as "discharge fraction" may all be sent in this segment.

9. 00090 · FRM · Follow-up action · Max 99 · Conditional

   To identify specific corrective actions that should occur before the adjudication process can complete. The identity number in this segment must be one of the identity number given in an ADI segment. The follow-up actions may be for the entire claim or may be service specific.

10. Segment group 1 Repeat 3

    1. 00110 · OTI · Other insurance · Max 1 · Mandatory

       To provide payer, insured and payment information when benefits are being coordinated between third party benefit carriers. A major source of concern in health care is being able to coordinate benefits between multiple insurance carriers. This segment will be used to reference other payers that may need to be kept abreast of the health care transaction and what monetary amounts are being paid by the respective carrier. Even though three different carriers may be identified, there is a yes or no indicator that will allow the indication of additional carriers beyond what is being sent.

    2. 00120 · NAA · Name and address · Max 2 · Conditional

       To specify identification numbers, name and address information relating to the other insurance parties. If available, the identification number of the insurance carrier should be used. When the identification number is not available, or the insurance carrier operates out of multiple offices, the name and/or address should be used.

11. Segment group 2 Repeat 99

    1. 00140 · PSI · Service information · Max 1 · Mandatory

       To provide detail information about the service, product, or procedure. This segment allows the payer of a health care transaction to indicate line item detail about all services performed. All charges can be broken down, several of the diagnosis codes from the claim can be references with an index identifier, and any supporting evidence and out of band additional information needed for the claim can be referenced.

    2. 00150 · DNT · Dental information · Max 35 · Conditional

       To provide specific a complete description of each tooth in relation to the service. Only in a dental claim, would the payer need to know specific tooth and additional information on the surface, gum depth or status.

12. 00160 · UIT · Interactive message trailer · Max 1 · Mandatory

    A service segment ending a message, giving the total number of segments in the message (including the UIH & UIT) and the control reference number of the message.

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