IHCLME Health care claim or encounter request and response

D11 Healthcare (SWG)

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. 0010 · UIH · Max 1 · Mandatory

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

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

3. 0030 · PRT · Party information · Max 9 · Conditional

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

4. 0040 · 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.

5. 0050 · CON · Contact information · Max 9 · Conditional

   To specify contact communication numbers and names.

6. 0060 · BLI · Billable information · Max 1 · Conditional

   To provide billable information for a claim or encounter.

7. 0070 · ITC · Institutional claim · Max 1 · Conditional

   To provide specific claim information for services performed while admitted to an institution.

8. 0080 · ADI · Health care claim adjudication information · Max 99 · Conditional

   To provide adjudication information for all services in a health care claim.

9. 0090 · FRM · Follow-up action · Max 99 · Conditional

   To identify a follow-up action that should occur.

10. Segment group 1 Repeat 3

    1. 0110 · OTI · Other insurance · Max 1 · Mandatory

       To provide payer, insured, and payment information when benefits are being coordinated between third party benefit carriers.

    2. 0120 · NAA · Name and address · Max 2 · 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.

11. Segment group 2 Repeat 99

    1. 0140 · PSI · Service information · Max 1 · Mandatory

       To provide detail information about the service.

    2. 0150 · DNT · Dental information · Max 35 · Conditional

       To provide specific tooth and oral cavity information.

12. 0160 · UIT · Max 1 · Mandatory