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

X12 270/271 V5
PHC 13045 (Rev. 4/08)
PDF (178 KB)
Revision Log

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

Note 1:

The REF segment of the 2100C loop of the 270 inquiry can contain either a subscriber’s Social Security number or a subscriber’s Medicaid Identification number. The first field of this segment, the REF01 reference identification qualifier, must contain one of the following two-byte values:

HJ — This value indicates that a Medicaid Identification number will follow in REF02. This code can be used as search criteria for Wisconsin Medicaid subscribers who present a Medicaid identification card with an associated PAN (primary account number).

SY — This value indicates that a subscriber’s Social Security number will follow in REF02. The subscriber's Social Security number can be used in conjunction with the subscriber name or date of birth as search criteria.

Note 2:

Reject Reason Code
25	Required application data missing
57	Invalid/missing dates of service
58	Invalid/missing date of birth
60	Date of birth follows date(s) of service
61	Date of death precedes date(s) of service
62	Date of service not within allowable inquiry period
63	Date of service in future
72	Invalid/missing subscriber ID
75	Subscriber not found
76	Duplicate subscriber ID number

Note 3:

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

Wisconsin Health Care Eligibility

Loop	Element	Name	Instruction
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 an 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 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 an 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” — Indicate Medicare Prescription Drug coverage when preceded by service type code 88 and followed by an 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

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

Loop	Element	Name	Instruction
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 an individual.
2110C	EB03	Service type code	This field will contain a value indicating what type of coverage is available from the subscriber's managed care program. 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, the EB segment will be repeated to indicate both codes.
2110C	EB04	Insurance type code	This field will contain the value “HM” to indicate health maintenance organization.

Lock in

Loop	Element	Name	Instruction
2110C	EB01	Eligibility or benefit information	This field will contain the value “N” to indicate a service restricted to the following provider.
2110C	EB02	Coverage level code	This field will contain the value “IND” to indicate an 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 50 — Hospital-Outpatient 88 — Pharmacy 96 — Professional (Physician)
2110C	EB04	Insurance type code	This field will contain the value “OT” to indicate “other.”

Private Insurance

Loop	Element	Name	Instruction
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 an 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.”

Note 4:

The contents of the REF segment in the 2110C loop of the 271 response will depend upon the information relayed in the associated EB segment. The contents will vary as in the following situations:

If the associated EB segment contains private insurance information, the REF segment will be returned twice. The segments will be populated as follows.

First Occurrence

Loop

Element

Name

Instruction

2110C

REF01

Reference identification qualifier

This field will contain the following value:

IG — Indicates that the subscriber's insurance policy number will follow in REF02

2110C

REF02

Reference identification

This field will contain the subscriber's insurance policy number.

Second Occurrence

Loop

Element

Name

Instruction

2110C

REF01

Reference identification qualifier

This field will contain the following value:

6P — Indicates that the subscriber's group number will follow in REF02

2110C

REF02

Reference identification

This field will contain the subscriber's group number.

If the associated EB segment contains Medicare information, the REF segment will be returned once. The segment will be populated as follows.

Loop

Element

Name

Instruction

2110C

REF01

Reference identification qualifier

This field will contain the following value:

F6 — Indicates that the subscriber's health insurance claim number will follow in REF02.

2110C

REF02

Reference identification

This field will contain the subscriber's health insurance claim (HIC) number.

X12 270 Eligibility Inquiry.
X12 271 Eligibility, Benefit Response.

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