Wisconsin Medicaid Companion Document to HIPAA Implementation Guide: X12 270/271 Eligibility, Coverage, or Benefit Inquiry and Response (Batch Process)

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Wisconsin Medicaid Companion Document to HIPAA Implementation Guide: X12 270/271 Eligibility, Coverage, or Benefit Inquiry and Response (Batch Process)

PHC 13092 (Rev. 2/06)
PDF (158 KB)
Revision Log

Attachment 1 — 270/271 Eligibility, Benefit, or Coverage Inquiry and Response Notes

The EB segment of the 2110C loop in the 271 eligibility response can contain many different types of information relating to the subscriber and can repeat several times. The following grids show the different types of information that can be returned in the EB segment.

Wisconsin Health Care Eligibility

Medicaid eligibility must be considered in conjunction with all other indicated benefits for appropriate billing. See 271 Interpretation Guidelines for more details.

Loop	Element	Name	Instructions
2110C	EB01	Eligibility or Benefit Information	This field will contain one of the following values: "1" — Indicates active coverage. "6" — Indicates inactive coverage. "T" — Indicates card reported lost or stolen. If this value is returned in EB01, the EB segment will be immediately terminated and EB02 – EB04 will not be present.
2110C	EB02	Coverage Level Code	This field will contain the value "IND" to indicate individual.
2110C	EB03	Service Type Code	If active coverage is indicated in EB01, this field will contain the value "30" to indicate health benefit plan coverage.
2110C	EB04	Insurance Type Code	This field will contain the value "MC" to indicate that Wisconsin Medicaid is the coverage being referenced.

Medicare

Loop	Element	Name	Instructions
2110C	EB01	Eligibility or Benefit Information	This field will contain the value “R” to indicate other or additional payer.
2110C	EB02	Coverage Level Code	This field will contain the value “IND” to indicate individual.
2110C	EB03	Service Type Code	This field will contain a value indicating what type of coverage is available from the subscriber's Medicare coverage: 30 — Indicates health benefit plan coverage, such as Medicare part A or B 88 — Indicates pharmacy plan coverage, such as Medicare Prescription Drug Coverage.
2110C	EB04	Insurance Type Code	This field will contain one of the following values: “MA” — Indicates that Medicare Part A is the coverage being referenced. “MB” — Indicates that Medicare Part B is the coverage being referenced. “OT” — Indicates Medicare Prescription Drug coverage when preceded by service type code 88 and followed by the MSG segment “Medicare Part D”
2110C	MSG01	Free-Form Message Text	This field will contain the value “Medicare Part D” to indicate Medicare Prescription Drug Coverage.

Medicaid Managed Care Program

This structure will be used for Family Care, Medicaid-contracted HMOs, and special managed care programs.

Loop	Element	Name	Instructions
2110C	EB01	Eligibility or Benefit Information	This field will contain the value “MC” to indicate managed care coordinator.
2110C	EB02	Coverage Level Code	This field will contain the value “IND” to indicate individual.
2110C	EB03	Service Type Code	This field will be populated if the subscriber’s managed care program covers either dental or chiropractic procedures. This field will contain either: “33” — Indicates the managed care program includes chiropractic coverage. “35” — Indicates the managed care program includes dental coverage. If the subscriber’s managed care program covers both chiropractic and dental procedures, the EB segment will be repeated, indicating both coverage codes.
2110C	EB04	Insurance Type Code	This field will contain the value “HM” to indicate HMO.

Lock-In

Loop	Element	Name	Instructions
2110C	EB01	Eligibility or Benefit Information	This field will contain the value “N” to indicate service restricted to the following provider.
2110C	EB02	Coverage Level Code	This field will contain the value “IND” to indicate individual.
2110C	EB03	Service Type Code	This field will contain one of the following values, indicating the category for which the subscriber is locked in: “35” — Dental Care. “45” — Hospice. “88” — Pharmacy.
2110C	EB04	Insurance Type Code	This field will contain the value “OT” to indicate other.

Private Insurance

Loop	Element	Name	Instructions
2110C	EB01	Eligibility or Benefit Information	This field will contain the value “R” to indicate other or additional payer.
2110C	EB02	Coverage Level Code	This field will contain the value “IND” to indicate individual.
2110C	EB03	Service Type Code	This field will contain the value “30” to indicate health benefit plan coverage.
2110C	EB04	Insurance Type Code	This field will contain the value “OT” to indicate other.

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