Emdeon Version 5 Standard Eligibility Response

Transcription

1 Table of Contents Emdeon Version 5 Standard Eligibility Response PC Response Dictionary Emdeon Max, Emdeon Assistant, Emdeon Direct, and Emdeon NetDirect

2 This publication is the proprietary property of Emdeon and is furnished solely for use pursuant to a license agreement giving the user the right to use the Emdeon product(s) referenced in this document. All uses of this document are subject to the terms of such license agreement. This document may not be used except as permitted by such license agreement or changed, copied, photocopied, reproduced, translated, or reduced to any electronic medium or machine readable form without the prior consent of Emdeon. Copyright is held by Emdeon Business Services, LLC. Emdeon is not liable for any losses or damages that result from the use of this material, including loss of profit or indirect, special, or consequential damages.

3 Table of Contents Table of Contents Introduction About This Document Customer Support Documentation on the Web Response Description Status Indicators Input and Response Information Transaction Information Information Source Information Source Contact Information Receiver Information Receiver Provider Information Subscriber Subscriber Additional ID Subscriber Provider Information Subscriber Diagnosis Code Subscriber Date Subscriber Military Personnel Information Patient Patient Additional ID Patient Provider Information Patient Diagnosis Code Patient Date Patient Military Personnel Information Eligibility/Benefit Values Eligibility/Benefit Types Service Types Insurance Types Entity Types Index Emdeon Business Services LLC. All rights reserved. Page iii

4 Introduction Introduction About This Document This document serves as a dictionary of the standard eligibility/benefit response data elements returned in version 5 of the Emdeon standard eligibility response, and displayed on your Emdeon MAX, NetDirect, or Assistant product. All of the items described in this response explanation will not appear in every response. A payer can omit fields or sections from the response, or can tailor the specific data returned. Note: For a dictionary of transaction-related errors, see the Dictionary of Transaction Error Messages. Customer Support customer.service@emdeon.com Documentation on the Web These documents are also available from our website at Choose the category Standard Response Guides Emdeon Business Services LLC. All rights reserved. Page 1

5 Response Description Response Description Status Closed The patient is eligible or is on file. Read the response for clarification. Retry The patient is ineligible or is not on file, or you entered invalid information, or Emdeon did not receive a valid standard response. Read the message in the response for clarification. Error A communications-related error or error of greater severity occurred. Read the message in the response for clarification. Indicators This information appears on the top of the report. The indicators show the following: Benefit Ind Indicates the presence or type of benefit information in the response. Common responses are: Y = Benefit information exists N = No benefit information exists P = Pending Q = QMB S = Spenddown Other Payer Ind Indicates the patient s Other Payer coverage. Common responses are: Y = Patient has Other Payer coverage. NA = Unable to determine if Other/Additional Payer information is present in the response from the payer. Medicare Ind Indicates the patient s Medicare coverage. Common responses are: A = Patient has Medicare Part A coverage. B = Patient has Medicare Part B coverage. A&B = Patient has Medicare Parts A and B coverage. NA = Unable to determine if Medicare information is present in the response from the payer Emdeon Business Services LLC. All rights reserved. Page 2

6 Response Description Input and Response Information The input area shows the data you sent in the request. For some of the input fields, the response area displays what the payer actually has on file. This arrangement enables you to verify what you entered against what is on file. Depending on your software product and report settings, response information fields can appear in one of two locations: They can appear in a column to the right of the input fields. They can appear beneath the input fields, with the heading (On File). An asterisk to the left of an input field indicates that the mirrored response data did not match your input data. Transaction Information The Transaction Information section returns reference information for this particular transaction. Submit ID The submitter transaction identifier is used to trace a transaction from point to point. Creation Date, Creation Time The date and time the transaction was generated by the payer/fiscal intermediary. The date is in MM/DD/CCYY format. The time is in HH:MM:SS format and based on a 24-hour clock. Benefit Ind Indicates the presence or type of benefit information in the response. Common responses are: Y = Benefit information exists N = No benefit information exists P = Pending Q = QMB S = Spenddown Medicare Ind Indicates the patient s Medicare coverage. Common responses are: A = Patient has Medicare Part A coverage. B = Patient has Medicare Part B coverage. A&B = Patient has Medicare Parts A and B coverage. NA = Unable to determine if Medicare information is present in the response from the payer. Other Payer Ind Indicates the patient s Other Payer coverage. Common responses are: Y = Patient has Other Payer coverage. NA = Unable to determine if Other/Additional Payer information is present in the response from the payer Emdeon Business Services LLC. All rights reserved. Page 3

7 Response Description Information Source The Information Source section identifies the source of the information being returned (typically, the payer). Primary ID The primary identification number for the information source. Name, First Name, Middle Name, Suffix The last name or organization name of the information source, and the first and middle names and suffix if the information source is a person and the information is provided. Information Source Contact The Information Source Contact section returns a contact name and up to three telephone numbers, Fax number, addresses, or URL (Uniform Resource Locator) to use when contacting the information source. Information Receiver The Information Receiver section identifies the receiver of the eligibility and benefit information. Typically, this section will identify you, as the submitter of the request. Primary ID The primary identification number for the information receiver. Name, First Name, Middle Name, Suffix The last name or organization name of the information receiver, and the first and middle names and suffix if the information receiver is a person and the information is provided. Information Receiver Provider Information The Information Receiver Provider Information section identifies the provider s role or type in the eligibility/benefit being inquired about and it identifies the provider s Taxonomy Code or specialty. Subscriber The Subscriber section returns trace numbers to identify the entities that have handled the transaction (payer and Emdeon data centers, for example). It also returns personal and demographic information about the subscriber, when the plan subscriber is the patient. Trace 1 through Trace 3 A number assigned by the processing entities to trace the transaction from point to point as it is processed. The source of the trace number follows. No Heading (Origin and Description) The originator of the preceding trace number. Additional information about the originator follows. Primary ID The subscriber s primary identification number. Last Name, First Name, Middle Name, Suffix The subscriber s last, first, and the middle names or initial and suffix Emdeon Business Services LLC. All rights reserved. Page 4

8 Date of Birth The subscriber s date of birth in MM/DD/CCYY format. Emdeon Version 5 Standard Eligibility Response PC Response Dictionary Response Description Gender The subscriber s gender. No Heading (Subscriber's Address) The subscriber s address. Birth Sequence A number assigned to each family member who is born with the same birth date. Change Indicates whether any identifying elements for the subscriber have changed from those submitted in the request. Subscriber Additional ID The Subscriber Additional ID section returns an identification number other than or in addition to the member identification number for the subscriber, such as the Medicare HIC, when used in addition to the payer s primary ID. The type of identification number is also described. This section can occur up to nine times. Subscriber Provider Information The Subscriber Provider Information section identifies the subscriber s provider s role or type, an additional identification qualifier, and provider ID or Taxonomy Code. Subscriber Diagnosis Code The Subscriber Diagnosis Code section lists the subscriber s principal diagnosis code, description, and code source and up to eight additional diagnosis codes, descriptions, and code sources. Subscriber Date A date or range of dates relating to the subscriber s eligibility/benefits. The type of date and/or time is also described. If the type of date returned in this section is Eligibility, Eligibility Begin, Eligibility End, Admission, or Service, it is implied that the date applies to all Eligibility/Benefit sections that follow unless there is a specific date in the Eligibility/Benefit section. Subscriber Military Personnel Information The Subscriber Military Personnel Information section returns information about the subscriber s military service, if applicable. This information is returned if the transaction is processed by the Department of Defense or CHAMPUS/TRICARE. Information Status The status of the subscriber s military personnel information (e.g., Current, Latest, Oldest, etc.). Employment Status The subscriber s general employment status (e.g., Active Military, Honorably discharged, etc.). Service Affiliation The subscriber s government service affiliation (e.g., Army, Air Force, Coast Guard, etc.) Emdeon Business Services LLC. All rights reserved. Page 5

9 Response Description MPI Description A free-form description that further identifies the subscriber s exact military unit. Military Rank The subscriber s current or most recent military rank. Service Date(s) The beginning date or date span of the subscriber s military service. Patient The Patient section is returned only for dependent inquiries. It returns trace numbers to identify the entities that have handled the transaction (payer and Emdeon data centers, for example). It also returns personal and demographic information about the patient, when the patient is considered a dependent of the subscriber and the inquiry itself is classified as a dependent query. Trace 1 through Trace 3 A number assigned by the processing entities to trace the transaction from point to point as it is processed. The source of the trace number follows. No Heading (Origin and Description) The originator of the preceding trace number. Additional information about the originator follows. Last Name, First Name, Middle Name, Suffix The patient s last, first, and the middle names or initial and suffix. Date of Birth The patient s date of birth in MM/DD/CCYY format. Gender The patient s gender. No Heading (Patient's Address) The patient s address. Relationship The relationship of the patient to the subscriber. Birth Sequence A number assigned to each family member who is born with the same birth date. Change Indicates whether any identifying elements for the patient have changed from those submitted in the request. Patient Additional ID The Patient Additional ID section returns an identification number other than or in addition to the member identification number for the patient, such as the Medicare HIC, when used in addition to the payer s primary ID. The type of identification number is also described. This section is returned when the patient is not the subscriber (for example, a spouse or dependent) Emdeon Business Services LLC. All rights reserved. Page 6

10 Patient Provider Information Emdeon Version 5 Standard Eligibility Response PC Response Dictionary Response Description The Patient Provider Information section identifies the patient s provider s role or type, an additional identification qualifier, and provider ID or Taxonomy Code. Patient Diagnosis Code The Patient Diagnosis Code section lists the patient s principal diagnosis code, description, and code source and up to eight additional diagnosis codes, descriptions, and code sources. Patient Date A date or range of dates relating to the patient s eligibility/benefits. The type of date and/or time is also described. If the type of date returned in this section is Eligibility, Eligibility Begin, Eligibility End, Admission, or Service, it is implied that the date applies to all Eligibility/Benefit sections that follow unless there is a specific date in the Eligibility/Benefit section. Patient Military Personnel Information The Patient Military Personnel Information section returns information about the patient s military service, if applicable. This information is returned if the transaction is processed by the Department of Defense or CHAMPUS/TRICARE. Information Status The status of the patient s military personnel information (e.g., Current, Latest, Oldest, etc.). Employment Status The patient s general employment status (e.g., Active Military, Honorably discharged, etc.). Service Affiliation The patient s government service affiliation (e.g., Army, Air Force, Coast Guard, etc.). MPI Description A free-form description that further identifies the patient s exact military unit. Military Rank The patient s current or most recent military rank. Service Date(s) The beginning date or date span of the patient s military service. Eligibility/Benefit The Eligibility/Benefit section returns specific eligibility and benefit information for the subscriber or patient. This section can occur up to 999 times. No Heading (Eligibility/Benefit Type Description) The type of eligibility or benefit being reported. See Eligibility/Benefit Types on page 11 for a list of eligibility or benefit types that can be returned in your response. No Heading (Coverage Description) A description of the level of coverage of benefits. No Heading (Service Type Description) A description of the classification of service. See Service Types on page Emdeon Business Services LLC. All rights reserved. Page 7

11 Response Description No Heading (Insurance Type Description) A description of the type of insurance policy. See Insurance Types on page 18. Plan Cvg Free-form text further describing the plan or coverage. Time Period A code and/or description which identifies the time period category for the benefits being described. Amount The amount associated with the benefit (in $9, format). Percent A percentage associated with the benefit (in 99% format). No Heading (Quantity Qualifier) A description of the type of benefit quantity. No Heading (Quantity) The benefit quantity. Authorization/Certification Indicates if authorization or certification is required. In Network Indicates if benefits are considered in- or out-of-plan network. No Heading (Product/Service ID Source Description) A description of the product/service ID or procedure code. No Heading (Product/Svc ID) The product/service ID or procedure code. If a range of procedure codes is used, this is the beginning value of the range (all procedure codes in the range apply). Procedure Modifier 1 through Procedure Modifier 4 A modifier for the product/service ID. Up to four modifiers may appear. Diag Cde Pntr1 through Diag Cde Pntr 4 The first pointer designates the primary diagnosis code for this response section. The other three pointers correspond to the additional diagnosis codes in the order of importance to the service. No Heading (Product/Svc ID 2) The product/service ID or procedure code. If a range of procedure codes is used, this is the ending value of the range (all procedure codes in the range apply). No Heading (Benefit Quantity 1 Qualifier through Benefit Quantity 9 Qualifier) A description of the type of benefit quantity. This field can occur up to nine times. No Heading (Benefit Quantity 1 through Benefit Quantity 9) The benefit quantity. This field can occur up to nine times Emdeon Business Services LLC. All rights reserved. Page 8

12 Response Description No Heading (Frequency 1 Qualifier through Frequency 9 Qualifier) The benefit frequency, in terms of the unit of measure; e.g., Week: 3 (three per week). This field can occur up to nine times. No Heading (Frequency 1 through Frequency 9) A text description of benefit frequency, in terms of the unit of measure; e.g., Week: 3 (three per week). This field can occur up to nine times. No Heading (Period 1 Qualifier through Period 9 Qualifier) The type of periods of delivery. This field can occur up to nine times. No Heading (Period 1 through Period 9) The number of periods of delivery. This field can occur up to nine times. No Heading (Delivery Frequency 1 through Delivery Frequency 9) A text description of the frequency of delivery; e.g., Mon thru Fri. This field can occur up to nine times. No Heading (Delivery Time 1 through Delivery Time 9) A text description of the delivery time; e.g., A.M. This field can occur up to nine times. No Heading (Additional Identification) A supplemental or additional identification type and identification number for the entity identified in the Eligibility/Benefit section. A free-form text description can follow. Up to nine identification types, identification numbers, and free-form text descriptions can appear. No Heading (Patient Dates) The type of date or time (e.g., Elig Begin) and the date or range of dates and/or time relating to the benefit in this Eligibility/Benefit section. The dates appear in MM/DD/CCYY format. Up to 20 additional dates and times can appear. No Heading (Messages) Free-form text message relating to the benefit reported in this Eligibility/Benefit section. Up to ten messages can appear. No Heading (Eligibility or Benefit Additional Information) Additional information about the nature of the patient s injury, the type of servicing facility, and any limitations to service at a particular facility. This information can appear up to ten times and can include the following lines of data: A description of whether the following data relates to the nature of an injury or to any limitations to service at a particular facility. The Nature of Injury Code or Facility Type Code and code description. A free-form text description of the benefit reported in this segment. No Heading (Benefit Related Entity) Identifies a type of entity related to the benefit returned in this Eligibility/Benefit section. May be used to identify the subscriber by name and/or identification number, a provider (for example, the primary care provider), an individual, another payer, or another information source. For a list of entity types, see Entity Types on page 20. Benefit-related entity information appears once and can include the following lines of data: The type of entity. The last name of the related entity or the organization name Emdeon Business Services LLC. All rights reserved. Page 9

13 Response Description The first name, middle name, and suffix, if the entity is a person. The related entity s ID code. The relationship of the patient to the entity. The type of provider, if applicable. The provider s Taxonomy Code or specialty. The related entity s address. The Department of Defense Health Service Region, if applicable. No Heading (Related Entity Contact) Additional contact information for the benefit related entity identified by the data described by the benefit related entity information above. Up to three contacts can appear with the following lines of data: The name of the contact. The type of contact information and either the telephone number (in or format), address, Fax number, or URL (Uniform Resource Locator) for the contact. Up to three contact numbers and/or addresses ( or URL) can appear for each contact Emdeon Business Services LLC. All rights reserved. Page 10

14 Values Values Eligibility/Benefit Types Value Actv Cvg Actv Full Risk Capitation Actv Srvcs Capitated Actv Srvcs Capitated to PCP Actv Pend Investigation Inactv Inactv Pend Elig Updte Inactv Pend Investigation Co-Ins Co-Pay Deductible Cvg Basis Bene Descrip Exclusions Limitations Out of Pckt (Stop Loss) Unlim Non-Cvd Cost Containment Rsv PCP Pre-existing Cond MC Coord Svces Restricted to Following Not Deemed a Med Necessity Bene Disclmr 2nd Surg Opinion Reqd Other/Addl Payer Prior Year(s) History Card(s) Rptd Lost/Stolen Contact Following for Elig/Bene Cannot Process Other Sce of Data Health Care Facility Description Active Coverage Active - Full Risk Capitation Active - Services Capitated Active - Services Capitated to Primary Care Physician Active - Pending Investigation Inactive Inactive - Pending Eligibility Update Inactive - Pending Investigation Co-Insurance Co-Payment Deductible Coverage Basis Benefit Description Exclusions Limitations Out of Pocket (Stop Loss) Unlimited Non-Covered Cost Containment Reserve Primary Care Provider Pre-existing Condition Managed Care Coordinator Services Restricted to Following Provider Not Deemed a Medical Necessity Benefit Disclaimer Second Surgical Opinion Required Other or Additional Payer Prior Year(s) History Card(s) Reported Lost/Stolen Contact Following Entity for Eligibility or Benefit Information Cannot Process Other Source of Data Health Care Facility 2011 Emdeon Business Services LLC. All rights reserved. Page 11

15 Values Value Spend Down Description Spend Down Service Types Code Abbreviations Description 1 Med Care Medical Care 2 Surg Surgical 3 Consultation Consultation 4 Dx X-Ray Diagnostic X-Ray 5 Dx Lab Diagnostic Lab 6 Radiation Thrpy Radiation Therapy 7 Anesth Anesthesia 8 Surg Asstnce Surgical Assistance 9 Other Medcl Other Medical 10 Blood Charges Blood Charges 11 Used DME Used Durable Medical Equipment 12 DME Purchase Durable Medical Equipment Purchase 13 Amb Svc Ctr Facility Ambulatory Service Center Facility 14 Renal Supplies in the Home Renal Supplies in the Home 15 Alternate Method Dial Alternate Method Dialysis 16 CRD Equipment Chronic Renal Disease (CRD) Equipment 17 Pre-Admin Testing Pre Admission Testing 18 DME Rent Durable Medical Equipment Rental 19 Pneumonia Vaccine Pneumonia Vaccine 20 Second Surg Opinion Second Surgical Opinion 21 Third Surg Opinion Third Surgical Opinion 22 Social Work Social Work 23 Dx Dntl Diagnostic Dental 24 Periodontics Periodontics 25 Restorative Restorative 26 Endodontics Endodontics 27 MFP Maxillofacial Prosthetics 28 Adjunctive Dntl Svcs Adjunctive Dental Services 30 Health Bene Plan Cvg Health Benefit Plan Coverage 2011 Emdeon Business Services LLC. All rights reserved. Page 12

16 Values Code Abbreviations Description 32 Plan Waiting Period Plan Waiting Period 33 Chiropractic Chiropractic 34 Chiropractic Office Visits Chiropractic Office Visits 35 Dntl Care Dental Care 36 Dntl Crowns Dental Crowns 37 Dntl Accident Dental Accident 38 Orthodontics Orthodontics 39 Prosthodontics Prosthodontics 40 Oral Surg Oral Surgery 41 Routine (Preventive) Dntl Routine (Preventive) Dental 42 HHC Home Health Care 43 HH Rxs Home Health Prescriptions 44 HH Visits Home Health Visits 45 Hspc Hospice 46 Respite Care Respite Care 47 Hosp Hospital 48 Hosp IP Hospital Inpatient 49 Hosp Room/Board Hospital Room and Board 50 Hosp OP Hospital Outpatient 51 Hosp Emergency Accident 52 Hosp Emergency Medical Hospital Emergency Accident Hospital Emergency Medical 53 Hosp Ambulatory Surg Hospital Ambulatory Surgical 54 LTC Long Term Care 55 Major Medical Major Medical 56 Medical Related Transport Medically Related Transportation 57 Air Transportation Air Transportation 58 Cabulance Cabulance 59 Licensed Ambulance Licensed Ambulance 60 General Benefits General Benefits 61 IVF In vitro Fertilization 62 MRI/CAT Scan MRI/CAT Scan 63 Donor Procedures Donor Procedures 64 Acupuncture Acupuncture 65 Newborn Care Newborn Care 66 Pa Pathology 2011 Emdeon Business Services LLC. All rights reserved. Page 13

17 Values Code Abbreviations Description 67 Smoking Cessation Smoking Cessation 68 Well Baby Care Well Baby Care 69 Maternity Maternity 70 Transplants Transplants 71 Audiology Exam Audiology Exam 72 Inhalation Thrpy Inhalation Therapy 73 Dx Medical Diagnostic Medical 74 Private Duty Nursing Private Duty Nursing 75 Prosthetic Device Prosthetic Device 76 Dial Dialysis 77 Otological Exam Otological Exam 78 CH Chemotherapy 79 Allergy Testing Allergy Testing 80 Immunizations Immunizations 81 Routine Physical Routine Physical 82 FP Family Planning 83 Infertility Infertility 84 Abortion Abortion 85 AIDS AIDS 86 Emergency Svcs Emergency Services 87 Cancer Cancer 88 Pharm Pharmacy 89 Free Standing Rx Drg Free Standing Prescription Drug 90 Mail Order Rx Drg Mail Order Prescription Drug 91 Brand Name Rx Drg Brand Name Prescription Drug 92 Generic Rx Drg Generic Prescription Drug 93 Podiatry Podiatry 94 Podiatry Office Visits Podiatry Office Visits 95 Podiatry Nursng Home Vsts Podiatry Nursing Home Visits 96 Professional (PHY) Professional (Physician) 97 Anesthesiologist Anesthesiologist 98 Prof (PHY) Visit Office Professional (Physician) Visit Office 99 Prof (PHY) Visit IP Professional (Physician) Visit Inpatient A0 Prof (PHY) Visit OP Professional (Physician) Visit Outpatient 2011 Emdeon Business Services LLC. All rights reserved. Page 14

18 Values Code Abbreviations Description A1 Prof (PHY) Vst Nursng Hme Professional (Physician) Visit Nursing Home A2 Prof (PHY) Visit SNF Professional (Physician) Visit Skilled Nursing Facility A3 Prof (PHY) Visit Home Professional (Physician) Visit Home A4 PC Psychiatric A5 PC Room/Board Psychiatric Room and Board A6 Psychotherapy Psychotherapy A7 PC IP Psychiatric Inpatient A8 PC OP Psychiatric Outpatient A9 Rehab Rehabilitation AA Rehab Room/Board Rehabilitation Room and Board AB Rehab IP Rehabilitation Inpatient AC Rehab OP Rehabilitation Outpatient AD OT Occupational Therapy AE Physical Medicine Physical Medicine AF Spch Thrpy Speech Therapy AG Skilled Nursing Care Skilled Nursing Care AH Sklled Nrsng Cre Rm & Brd Skilled Nursing Care Room and Board AI SA Substance Abuse AJ Alcoholism Alcoholism AK Drg Addiction Drug Addiction AL Vision (Optometry) Vision (Optometry) AM Frames Frames AN Routine Exam Routine Exam AO Lenses Lenses AQ Nonmedical Ncessry Physical Nonmedically Necessary Physical AR Experimental Drg Thrpy Experimental Drug Therapy B1 Burn Care Burn Care B2 Brand Nm Rx-Formulary Brand Name Prescription Drug - Formulary B3 BA Brand Nm Rx- NonFormulary Independent Medical Eval Brand Name Prescription Drug - Non-Formulary Independent Medical Evaluation BB Prtl Hospitalization (PC) Partial Hospitalization (Psychiatric) 2011 Emdeon Business Services LLC. All rights reserved. Page 15

19 Values Code Abbreviations Description BC Day Care (PC) Day Care (Psychiatric) BD Cognitive Thrpy Cognitive Therapy BE Massage Thrpy Massage Therapy BF Pulmonary Rehab Pulmonary Rehabilitation BG Cardiac Rehab Cardiac Rehabilitation BH Peds Pediatric BI Nursery Nursery BJ Skin Skin BK Orthopedic Orthopedic BL Cardiac Cardiac BM Lymphatic Lymphatic BN GI Gastrointestinal BP Endocrine Endocrine BQ Neuro Neurology BR Eye Eye BS Invasive Procs Invasive Procedures BT Gynecological Gynecological BU Obstetrical Obstetrical BV BW Obstetrical/ Gynecological Mail Order Rx-Brand Name Obstetrical/ Gynecological Mail Order Prescription Drug: Brand Name BX Mail Order Rx-Generic Mail Order Prescription Drug: Generic BY PHY Visit/Office-Sick Physician Visit/Office: Sick BZ PHY Visit/Office-Well Physician Visit/Office: Well C1 Coronary Care Coronary Care CA Private Duty Nursing-IP Private Duty Nursing - Inpatient CB Private Duty Nursing- Home Private Duty Nursing - Home CC Surgical Benefits-PHY Surgical Benefits - Professional (Physician) CD Surgical Benefits-Facility Surgical Benefits - Facility CE CF Mental Health Provider- IP Mental Health Provider- OP Mental Health Provider - Inpatient Mental Health Provider - Outpatient CG Mental Health Facility-IP Mental Health Facility - Inpatient CH Mental Health Facility- OP Mental Health Facility - Outpatient 2011 Emdeon Business Services LLC. All rights reserved. Page 16

20 Values Code Abbreviations Description CI SA Facility-IP Substance Abuse Facility - Inpatient CJ SA Facility-OP Substance Abuse Facility - Outpatient CK Screening X-Ray Screening X-Ray CL Screening Lab Screening Laboratory CM CN Mammogram-high risk patient Mammogram-low risk patient Mammogram, high risk patient Mammogram, low risk patient CO Flu Vaccination Flu Vaccination CP Eyewear/Accessories Eyewear and Eyewear Accessories CQ Case Management Case Management DG Dermatology Dermatology DM DME Durable Medical Equipment DS Diabetic Supplies Diabetic Supplies GF Generic Rx-Formulary Generic Prescription Drug - Formulary GN Generic Rx- NonFormulary GY Allergy Allergy Generic Prescription Drug - Non-Formulary IC IC Intensive Care MH Mental Health Mental Health NI Neonatal IC Neonatal Intensive Care ON Oncology Oncology PT PT Physical Therapy PU Pulmonary Pulmonary RN Renal Renal RT Residential Psychiatric Residential Psychiatric Treatment TC Transitional Care Transitional Care TN Transitional Nursery Care UC Urgent Care Urgent Care Transitional Nursery Care 2011 Emdeon Business Services LLC. All rights reserved. Page 17

21 Values Insurance Types Abbreviation in Response Mcare 2ndary Working Aged Beneficiary or Spouse with EGHP Mcare 2ndary ESRD Beneficiary in the 12 mo coordination period with an EGHP Mare 2ndary, No-fault Ins including Auto is Primary Mcare 2ndary Work Comp Mcare 2ndary PHS or Other Federal Agency Mcare 2ndary Black Lung Mcare 2ndary Vets Admin Mcare 2ndary Disabled Beneficiary Under Age 65 with LGHP Mcare 2ndary, Other Liability Ins is Primary Auto Ins Pol Comm COBRA Mcare Conditionally Primary Disability Disability Benes Exclusive Provider Organization Fam or Friends Grp Pol HMO HMO Mcare Risk Spcl Low Income Medicare Beneficiary Indemnity Indiv Pol LTC Long Term Pol Life Ins Description Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer group health plan Medicare Secondary, No-fault Insurance including Auto is Primary Medicare Secondary Workers Compensation Medicare Secondary Public Health Service (PHS) or Other Federal Agency Medicare Secondary Black Lung Medicare Secondary Veterans Administration Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) Medicare Secondary, Other Liability Insurance is Primary Auto Insurance Policy Commercial Consolidated Omnibus Budget Reconciliation Act (COBRA) Medicare Conditionally Primary Disability Disability Benefits Exclusive Provider Organization Family or Friends Group Policy Health Maintenance Organization (HMO) Health Maintenance Organization (HMO) Medicare Risk Special Low Income Medicare Beneficiary Indemnity Individual Policy Long Term Care Long Term Policy Life Insurance 2011 Emdeon Business Services LLC. All rights reserved. Page 18

22 Values Abbreviation in Response Litigation Mcare A Mcare B Mcaid Mgap A Mgap B Mcare Primary Other Property Ins Personal Personal Personal Payment (Cash - No Ins) PPO POS QMB Property Ins Real Supplemental Pol TEFRA Work Comp Wrap Up Pol Description Litigation Medicare Part A Medicare Part B Medicaid Medigap Part A Medigap Part B Medicare Primary Other Property Insurance Personal Personal Personal Payment (Cash - No Insurance) Preferred Provider Organization (PPO) Point of Service (POS) Qualified Medicare Beneficiary Property Insurance Real Supplemental Policy Tax Equity Fiscal Responsibility Act (TEFRA) Workers Compensation Wrap Up Policy 2011 Emdeon Business Services LLC. All rights reserved. Page 19

23 Values Entity Types Abbreviation in Response Contracted Svc Prov PPO Prov Third-Party Admin Employer Other PHY Hosp Facility Gateway Prov Group IPA Insured or Sub Legal Rep PCP Prior Ins Carrier Plan Sponsor Payer Primary Payer 2ndary Payer Tertiary Payer Vendor Org Complete Config Change Utilization Management Org Description Contracted Service Provider Preferred Provider Organization Provider Third-Party Administrator Employer Other Physician Hospital Facility Gateway Provider Group Indendent Physicians Association Insured or Subscriber Legal Representative Primary Care Provider Prior Insurance Carrier Plan Sponsor Payer Primary Payer Secondary Payer Tertiary Payer Vendor Organization Completing Configuration Change Utilization Management Organization 2011 Emdeon Business Services LLC. All rights reserved. Page 20

24 Index Index A About This Document, 1 Amount, 8 Authorization/Certification, 8 B Benefit Ind, 1, 2 Birth Sequence, 5, 6 C Change, 5, 6 Closed, 1 Creation Date, Creation Time, 2 Customer Support, 1 D Date of Birth, 4, 6 Diag Cde Pntr1 through Diag Cde Pntr 4, 8 Documentation on the Web, 1 E Eligibility/Benefit, 7 Eligibility/Benefit Types, 10 Eligibility/Benefit Values, 10 Employment Status, 5, 7 Entity Types, 20 Error, 1 G Gender, 4, 6 I In Network, 8 Indicators, 1 Information Receiver, 4 Information Receiver Provider Information, 4 Information Source, 3 Information Source Contact, 4 Information Status, 5, 7 Input and Response Information, 2 Insurance Types, 18 L Last Name, First Name, Middle Name, Suffix, 4, 6 M Medicare Ind, 2 Military Rank, 6, 7 MPI Description, 5, 7 N Name, First Name, Middle Name, Suffix, 3, 4 No Heading (Additional Identification), 9 No Heading (Benefit Quantity 1 Qualifier through Benefit Quantity 9 Qualifier), 9 No Heading (Benefit Quantity 1 through Benefit Quantity 9), 9 No Heading (Benefit Related Entity), 10 No Heading (Coverage Description), 7 No Heading (Delivery Frequency 1 through Delivery Frequency 9), 9 No Heading (Delivery Time 1 through Delivery Time 9), 9 No Heading (Eligibility or Benefit Additional Information), 9 No Heading (Eligibility/Benefit Type Description), 7 No Heading (Frequency 1 Qualifier through Frequency 9 Qualifier), 9 No Heading (Frequency 1 through Frequency 9), 9 No Heading (Insurance Type Description), 8 No Heading (Messages), 9 No Heading (Origin and Description), 4, 6 No Heading (Patient Dates), 9 No Heading (Patient's Address), 6 No Heading (Period 1 Qualifier through Period 9 Qualifier), 9 No Heading (Period 1 through Period 9), 9 No Heading (Product/Service ID Source Description), 8 No Heading (Product/Svc ID 2), 8 No Heading (Product/Svc ID), 8 No Heading (Quantity Qualifier), 8 No Heading (Quantity), 8 No Heading (Related Entity Contact), 10 No Heading (Service Type Description), 8 No Heading (Subscriber's Address), 5 O Other Payer Ind, 2, 3 P Patient, 6 Patient Additional ID, 6 Patient Date, 7 Patient Diagnosis Code, 7 Patient Military Personnel Information, 7 Patient Provider Information, 7 Percent, 8 Plan Cvg, 8 Primary ID, 3, 4 Procedure Modifier 1 through Procedure Modifier 4, 8 R Relationship, 6 Retry, 1 S Service Affiliation, 5, 7 Service Date(s), 6, 7 Service Types, 12 Status, 1 Submit ID, 2 Subscriber, 4 Subscriber Additional ID, 5 Subscriber Date, 5 Subscriber Diagnosis Code, 5 Subscriber Military Personnel Information, 5 Subscriber Provider Information, Emdeon Business Services LLC. All rights reserved. Page 21

25 Index T Time Period, 8 Trace 1 through Trace 3, 4, 6 Transaction Information, 2 V Value Descriptions, Emdeon Business Services LLC. All rights reserved. Page 22

26 Emdeon is a leading provider of revenue and payment cycle solutions that connect payers, providers, and patients to improve the healthcare business processes. To learn more about our company, our services, and our commitment to improving healthcare, visit our website at Emdeon Business Services LLC. All rights reserved Lebanon Pike, Suite 1000 Nashville, TN EMDEON.6 ( )