{"id":1857,"date":"2024-12-06T18:19:13","date_gmt":"2024-12-07T02:19:13","guid":{"rendered":"https:\/\/www.qualityhealth.org\/adminsimp\/?page_id=1857"},"modified":"2024-12-06T18:25:41","modified_gmt":"2024-12-07T02:25:41","slug":"hipaa-transaction-bpr-requesting-and-receiving-coverage-information-for-eligibility-and-benefits","status":"publish","type":"page","link":"https:\/\/www.qualityhealth.org\/adminsimp\/hipaa-transaction-bpr-requesting-and-receiving-coverage-information-for-eligibility-and-benefits\/","title":{"rendered":"HIPAA Transaction BPR: Requesting and Receiving Coverage Information for Eligibility and Benefits"},"content":{"rendered":"

[vc_row][vc_column][vc_column_text css=””]<\/p>\n

Related BPR<\/strong><\/h4>\n

Requesting and Receiving Coverage Information for Eligibility and Benefits (HIPAA 270-271)<\/a><\/p>\n

<\/p>\n

<\/span><\/h4>\n

[\/vc_column_text][vc_column_text css=””]<\/p>\n

Summary Findings<\/strong><\/h4>\n
<\/div>\n

[\/vc_column_text][vc_toggle title=”Cigna” custom_font_container=”tag:h4|text_align:left|color:%231E73BE” custom_google_fonts=”font_family:Anton%3Aregular|font_style:400%20regular%3A400%3Anormal” css=”” use_custom_heading=”true”]Latest Validation:<\/strong>\u00a0June 2015<\/p>\n

BPR:\u00a0<\/strong>Version 2.5<\/p>\n

Worksheet Version:<\/strong>\u00a0041115a<\/p>\n

Updated:<\/strong>\u00a0March 2017<\/p>\n

\n
    \n
  • Cigna is aware of \u201cgaps\u201d where data fields in the transaction are not populated but the associated information is available on the web site. \u00a0Action to be taken:<\/em>\u00a0Looking at the eligibility engine since it is not providing all the data at this time.\u00a0\u00a0Completion date<\/em>:\u00a0 No ETA.<\/li>\n
  • Occasionally, multiple eligibility records may be created and the incorrect one is not deleted from the system.\u00a0 The transaction may report information from the incorrect record rather than the correct record. \u00a0Action to be taken:<\/em>\u00a0This is an eligibility loading issue, unsure of how they are addressing this as this time\u00a0\u00a0Completion date<\/em>:\u00a0 No ETA.<\/li>\n
  • Cigna does not report benefits in the transaction for services that have been \u201ccarved out\u201d, e.g. pharmacy.\u00a0\u00a0Action to be taken:<\/em>\u00a0Telephone number currently provided, no changes are being made.\u00a0Completion date<\/em>:\u00a0 No ETA.<\/li>\n<\/ul>\n

    [\/vc_toggle][vc_toggle title=”Regence” custom_font_container=”tag:h4|text_align:left|color:%231E73BE” custom_google_fonts=”font_family:Anton%3Aregular|font_style:400%20regular%3A400%3Anormal” css=”” use_custom_heading=”true”]Validation:<\/strong>\u00a0April 2016<\/p>\n

    BPR:<\/strong>\u00a0Version 2.3<\/p>\n

    Updated:<\/strong>\u00a0February\u00a02018<\/p>\n

    These findings apply to all products related to Payer ID = 87726. They do not apply to Medicaid or Medicare Products.<\/p>\n

    \n

    Member Information<\/em>:<\/p>\n

    \n

    When patient is the subscriber, an INS segment is not reported in the 271 to indicate relationship of \u201cSelf\u201d.\u00a0Action to be Taken<\/em>\u00a0TR3 for the 271 does not require the reporting of an INS segment for \u201cself\u201d.\u00a0Completion Date<\/em>: N\/A<\/p>\n<\/blockquote>\n

    Plan (EB03=30) and Service Level (EB03 = Service Type) Information<\/em>:<\/p>\n

    \n

    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).\u00a0Action to be Taken:<\/em>\u00a0See below.\u00a0Completion Date<\/em>: N\/A<\/p>\n

    UHC does not consider this an issue and refers providers to page 21 of their Companion Guide,\u201cIn the generic response (EB03=30) when benefit co-pay\/co-insurance\/deductible information for 48 \u2013Hospital-Inpatient and 50 \u2013 Hospital-Outpatient are included in the response, then 47 \u2013 Hospital will not include benefit co-pay\/co-insurance\/deductible information.\u201d<\/p>\n<\/blockquote>\n

    [\/vc_toggle][vc_toggle title=”United Healthcare (Payer ID 87726)” custom_font_container=”tag:h4|text_align:left|color:%231E73BE” custom_google_fonts=”font_family:Anton%3Aregular|font_style:400%20regular%3A400%3Anormal” css=”” use_custom_heading=”true”]Latest Validation:<\/strong>\u00a0December\u00a02016<\/p>\n

    BPR:\u00a0<\/strong>Version 3.91<\/p>\n

    Worksheet Version:<\/strong>\u00a0071416a<\/p>\n

    \n

    High Impact Best Practices:<\/b>\u00a022\u00a0of 22\u00a0are met.<\/p>\n

    Medium Impact Best Practices:\u00a0<\/b>10\u00a0of 10\u00a0are met.[\/vc_toggle][\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"[vc_row][vc_column][vc_column_text css=””] Related BPR Requesting and Receiving Coverage Information for Eligibility and Benefits (HIPAA 270-271) [\/vc_column_text][vc_column_text css=””] Summary Findings [\/vc_column_text][vc_toggle title=”Cigna” custom_font_container=”tag:h4|text_align:left|color:%231E73BE” custom_google_fonts=”font_family:Anton%3Aregular|font_style:400%20regular%3A400%3Anormal” css=”” use_custom_heading=”true”]Latest Validation:\u00a0June 2015 BPR:\u00a0Version 2.5 Worksheet Version:\u00a0041115a Updated:\u00a0March 2017 Cigna is aware of \u201cgaps\u201d where data fields in the transaction are not populated but the associated information is available on the…","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-1857","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.qualityhealth.org\/adminsimp\/wp-json\/wp\/v2\/pages\/1857","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.qualityhealth.org\/adminsimp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.qualityhealth.org\/adminsimp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.qualityhealth.org\/adminsimp\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.qualityhealth.org\/adminsimp\/wp-json\/wp\/v2\/comments?post=1857"}],"version-history":[{"count":4,"href":"https:\/\/www.qualityhealth.org\/adminsimp\/wp-json\/wp\/v2\/pages\/1857\/revisions"}],"predecessor-version":[{"id":1861,"href":"https:\/\/www.qualityhealth.org\/adminsimp\/wp-json\/wp\/v2\/pages\/1857\/revisions\/1861"}],"wp:attachment":[{"href":"https:\/\/www.qualityhealth.org\/adminsimp\/wp-json\/wp\/v2\/media?parent=1857"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}