HIPAA Transaction BPR: Requesting and Receiving Coverage Information for Eligibility and Benefits
Latest Validation: June 2015
BPR: Version 2.5
Worksheet Version: 041115a
Updated: March 2017
- Cigna is aware of “gaps” where data fields in the transaction are not populated but the associated information is available on the web site. Action to be taken: Looking at the eligibility engine since it is not providing all the data at this time. Completion date: No ETA.
- Occasionally, multiple eligibility records may be created and the incorrect one is not deleted from the system. The transaction may report information from the incorrect record rather than the correct record. Action to be taken: This is an eligibility loading issue, unsure of how they are addressing this as this time Completion date: No ETA.
- Cigna does not report benefits in the transaction for services that have been “carved out”, e.g. pharmacy. Action to be taken: Telephone number currently provided, no changes are being made. Completion date: No ETA.
Latest Validation: February 2017
BPR: Version 2.5
Worksheet Version: 091216a
- Regence only allows for one Service Type to be entered in the 270’s EQ01. If multiple service types are entered into EQ01, then a ‘30’ response is returned. On the 271. Action to be taken: None
- An other coverage EB*R segment containing “No Other Insurance” as the name of the over coverage will be reported if/when Regence removes a member’s secondary coverage within their COB file, i.e. other coverage will be indicated even when there is no other coverage. Action to be taken: None
- Re Coverage Date: 12/31/9999 is the default termination date that is put into the 271 transaction if a specific termination date has not been entered for that member. Some transactions may contain 12/31/9999 and some may not, depending upon whether an actual termination date has been entered for that member.
- If the patient has multiple coverage by Regence, a group number must be entered so that the specific coverage will be presented.
United Healthcare (Payer ID 87726)
Validation: April 2016
BPR: Version 2.3
Updated: February 2018
These findings apply to all products related to Payer ID = 87726. They do not apply to Medicaid or Medicare Products.
When patient is the subscriber, an INS segment is not reported in the 271 to indicate relationship of “Self”. Action to be Taken TR3 for the 271 does not require the reporting of an INS segment for “self”. Completion Date: N/A
Plan (EB03=30) and Service Level (EB03 = Service Type) Information:
For Hospital (Service Type = 47), 47 is identified as an active benefit in the EB01=1, even though no benefit information is reported at the plan level (EB03=30) or the service level (EB03=47). Action to be Taken: See below. Completion Date: N/A
UHC does not consider this an issue and refers providers to page 21 of their Companion Guide,“In the generic response (EB03=30) when benefit co-pay/co-insurance/deductible information for 48 –Hospital-Inpatient and 50 – Hospital-Outpatient are included in the response, then 47 – Hospital will not include benefit co-pay/co-insurance/deductible information.”