IHCEBI Interactive health insurance eligibility and benefits inquiry and response

TBG10 Healthcare

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

   A service segment starting and uniquely identifying a message. The message type code for the Interactive health insurance eligibility and benefits inquiry and response is IHCEBI. Note: Interactive health insurance eligibility and benefits inquiry and responses conforming to this document must contain the following data in segment UIH, composite S306: Data element 0065 IHCEBI 0052 D 0054 16A 0051 UN

   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. 00020 · MSD · Message action details · Max 1 · Mandatory

   Use to specify the message and processing requirements, for example, the type of health care insurance verification to be done and to provide a tracking mechanism for the submitter of the message. The reference number in this segment will provide an application level tracking number, which is different from what is generated in the message envelope.

3. Segment group 1 Repeat 9

   1. 00040 · PRT · Party information · Max 1 · Mandatory

      To provide specific entity identifiers or demographic information regarding the identity of the participating parties. For individuals identifiers will include date of birth, or a health plan insurance card date of issue as shown on the card may be specified in this segment, when the segment is identifying a health plan subscriber.

   2. 00050 · NAA · Name and address · Max 9 · Conditional

      Use to specify a party identity, and when necessary, the name and address of an entity and their related function in either a structured or unstructured format. For use in health care, it is recommended to use only the name and identifier, but when name and address are required use only the structured method of submittal. This segment is providing the name and address of the party identified in the Associated Parties Group.

   3. 00060 · CON · Contact information · Max 9 · Conditional

      Use to specify contact communication numbers, names, and electronic message routing information. Use to provide information about contacts within an organization or associated with the party identified in the Associated Parties Loop who can be called upon for further or clarifying information. The reference number may be used to provide a unique number for the contact entity to use when referring to this message.

   4. 00070 · FRM · Follow-up action · Max 9 · Conditional

      Used only with the response message, this will identify specific corrective actions or follow-up that should occur before another inquiry is made about this entity. Errors reported here related to the parties identified in the Associated Parties Group. For example, provider is not authorised to inquire against this payer's files.

4. Segment group 2 Repeat 1

   1. 00090 · DTI · Date and time information · Max 1 · Mandatory

      Use to specify dates that will common to each benefit or covered service. On the request message, this segment will be used to specify the service or planned service dates for the benefits in question. On the response message, this segment will specify the effective dates of benefit coverage for all listed benefits. The information in this segment can be overridden for a specific benefit, when effective or termination dates are different from the overall plan. This is done in the Health Insurance Benefit Details Group for each reported benefit where it applies.

   2. 00100 · ICI · Insurance cover information · Max 1 · Conditional

      Use to specify a type of insurance, this will apply to all information that follows.

   3. 00110 · FRM · Follow-up action · Max 9 · Conditional

      To identify specific corrective actions or follow-up that should occur before another inquiry is made about the patient in the request message. This segment is only sent with the response message when there are errors to report related to the benefit information request message within the Global Benefit and Service Coverage Group. For example, an invalid service date or insurance type was specified.

   4. Segment group 3 Repeat 999

      1. 00130 · BCD · Benefit and coverage detail · Max 1 · Mandatory

         Use to specify specific benefits and associated coverage. When used on the request message, it will specify a specific benefit or covered service in question. When used on the response, it will provide information about the requested health insurance benefits and coverage available, plus any additional administrative information that may have a business or patient care impact to the party making the inquiry.

      2. 00140 · HDS · Health diagnosis service and delivery · Max 9 · Conditional

         Use to specify diagnosis information and procedure or therapy services and details about how and when these services can be delivered, based on the diagnosis or procedure or contract terms or all of these. When this information is sent on the request, it is describing the diagnosis of the patient and asking about benefit coverage for a specific procedure or therapy. When the information is sent on the response, it is providing information from the health insurance plan about what benefit coverage is available, for certain procedures based on the diagnosis and what service delivery requirements exist, which can vary based on diagnosis, procedure, and health plan contract.

      3. 00150 · DTI · Date and time information · Max 1 · Conditional

         Use to specify eligibility dates related to the benefit or service described in the current iteration of the Health Insurance Benefit Details Group. When used at this level on the request message, it is to specify service dates from the provider that are outside of the service dates specified in the Global Benefit Service Details Group. When used at this level on the response message it identifies eligibility start or termination dates assigned by the responder that override the overall eligibility dates identified in the earlier Global Benefit Service Details Group.

      4. 00160 · PRT · Party information · Max 9 · Conditional

         Use to reference a specific payer or provider for the benefit or service identified in the current Health Insurance Benefit Details Group. The payer or provider should be in the list of parties identified within the Associated Parties Group, where full details of the entity should be provided, including name, address, and contact information. The payer is most likely used for third party liability for coordination of benefits. Identified providers would be those restricted to providing services for the identified benefit, for example, a capitated provider.

      5. 00170 · FRM · Follow-up action · Max 9 · Conditional

         Use to identify specific corrective actions or follow-up that should occur before another inquiry is made about this subject entity, that is, the patient or health plan subscriber. Errors reported at this level of the message are benefit specific, reporting processing errors from the responding application associated with the benefit inquiry request.

5. 00180 · 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.