270/271 Health Care Eligibility, Coverage, or Benefit Inquiry and Response

Transcription

1 Companion Document 270/ /271 Health Care Eligibility, Coverage, or Benefit Inquiry and Response Basic Instructions This section provides information to help you prepare for the ANSI ASC X Eligibility, Coverage, or Benefit Inquiry (270) and the ANSI ASC X Eligibility, Coverage, or Benefit Response (271) transactions. The remaining sections of this appendix include tables that provide specific instructions about 270 and 271 segments and data elements to process efficiently through Anthem East systems. Use this companion document in conjunction with both the Transaction Set Implementation Guide Health Care Eligibility, Coverage, or Benefit Inquiry and Response, 270/271, ASC X12N 270/271 (004010X092), May 2000, and the subsequent Addenda (004010X092A1), October 2002, published by the Washington Publishing Co. NOTE! All required segments and data elements populated in the 270 Request Transaction will appear in the 271 Response Transaction. Anthem Blue Cross and Blue Shield - East Region Page 1 of 24 Release 04 (June 2006) Version A1 - Oct 2002

2 1 X12 and HIPAA Compliance Checking, and Business Edits Level 1. Anthem East returns a 997 Functional Acknowledgment to the submitter for every inbound 270 Eligibility, Coverage or Benefit Inquiry transaction received. Each transaction passes through edits to ensure that it is X12 compliant. If the X12 syntax or any other aspect of the 270 Eligibility, Coverage or Benefit Inquiry is not X12 compliant, the 997 Functional Acknowledgment will also report the Level 1 errors in AK segments and indicate that the entire transaction set has been rejected. Level 2. HIPAA Implementation Guide edits are strictly enforced. If an error is encountered, Anthem East will return an 864 Text Message Transaction (Code Set Error Report) to the submitter listing the Level 2 HIPAA compliance errors and indicating the entire transaction set has been rejected. 2 Business Purpose The purpose of generating a 270 Eligibility, Coverage or Benefit Inquiry is to make a simple eligibility status inquiry or a request for co-pays. In order for Anthem East (CT, ME) to identify the patient correctly, the following five primary identifiers must be supplied: 1) Patient s First Name (NM104) 2) Patient s Last Name (NM103) 3) Patient s Date of Birth (DMG02) 4) Subscriber ID Number as it appears on Anthem ID card (NM109) 5) Dates of Eligibility Requested by Provider (DTP03) [As of 2/10/03, not confirmed] In order for Anthem East (NH) to identify the patient correctly, the following three primary identifiers must be supplied: 1) Patient s First Name (NM104) 2) Subscriber ID Number as it appears on Anthem ID card (NM109) 3) Dates of Eligibility Requested by Provider (DTP03) When the criteria are not met, the AAA segments of the 271 Response will indicate that the 270 Inquiry has been rejected. Anthem Blue Cross and Blue Shield - East Region Page 2 of 24 Release 04 (June 2006) Version A1 - Oct 2002

3 3 Response You will receive a response to your inquiry within 24 hours. The information provided is only as accurate as on the day the request is made. For Anthem East (NH), the following segments and data elements will be returned on the 271 response when the information is populated on the 270 request: Loop 2100C, REF Subscriber Additional Identification Loop 2100C, DMG Subscriber Demographic Information Loop 2100C, INS Subscriber Relationship 4 Delimiters Anthem East accepts any of the standard delimiters as defined by the ANSI standards. The more commonly used delimiters include the following: Data Element Separator, Asterisk, (*) Sub-Element Separator, Colon, (:) Segment Terminator, Tilde (~) These delimiters are for illustration purposes only and are not specific recommendations or requirements. 5 National Provider Identifier (NPI) Beginning October 2006 through May 22, 2007, providers can submit both legacy provider identifiers and NPIs on the 270 Inquiry. This dual receipt period accommodates the time in which NPIs are assigned to providers during the year. On and after the compliance date of May 23, 2007, providers are required to use NPI as their primary ID (replaces the legacy provider identifier) for all electronic transactions. The NPI will be populated in its 10-position, all numeric format on the returning 271 response. DUAL RECEIPT Name Secondary Identification Loop NM101 NM108 NM109 REF01 REF02 NPI XX NPI TJ Tax ID 2100B - Information Receiver Name 1P No NPI SV Provider No. TJ Tax ID Anthem Blue Cross and Blue Shield - East Region Page 3 of 24 Release 04 (June 2006) Version A1 - Oct 2002

4 270 Health Care Eligibility, Coverage or Benefit Inquiry Header The 270 Eligibility, Coverage, or Benefit Inquiry Header identifies the start of the transaction, the specific transaction set, and its business purpose. A data element in the header, BHT01 (Hierarchical Structure Code) relates the type of business data expected within each level. The following table indicates the specific values of the required header segments and data elements for Anthem East processing. 270 Eligibility, Coverage or Benefit Inquiry Header IG Segment Reference P.36 ST Transaction Set Header P.38 BHT Beginning of Hierarchical Transaction ST01 Transaction Set ST02 Transaction Set Control Number BHT01 Hierarchical Structure Code BHT02 Transaction Set Purpose Code BHT03 Reference Identification BHT04 Date BHT05 Time Eligibility, Coverage or Benefit Inquiry (Identical to SE02) Unique value Information Source, Information Receiver, Subscriber, Dependent Request (Submitter Transaction Identifier) (Transaction Set Creation Date) (Transaction Set Creation Time) will be returned on corresponding 271 Date when 270 transaction created Time when 270 transaction created Anthem Blue Cross and Blue Shield - East Region Page 4 of 24 Release 04 (June 2006) Version A1 - Oct 2002

5 270 Health Care Eligibility, Coverage or Benefit Inquiry Detail The 270 Eligibility, Coverage or Benefit Inquiry Detail level contains all data relating to the requested transaction, including transaction participants, the subscriber, the dependent, and the patient detail information. Using a hierarchical level (HL) structure, the four levels for the participant types include: Information Source Level. The Information Source is the payer that maintains the information regarding the patient s coverage. NOTE! Information source does not refer to the entity sending the transaction. Information Receiver Level. The Information Receiver is the entity requesting information regarding the patient s coverage and is typically the medical service provider verifying insurance coverage for the patient. Subscriber Level. The subscriber, who may or may not be the patient, is uniquely identified to an Information Source, traditionally referred to as a member. Dependent Level. The dependent, who may or may not be the patient, is related to the subscriber. Anthem Blue Cross and Blue Shield - East Region Page 5 of 24 Release 04 (June 2006) Version A1 - Oct 2002

6 1 270 Health Care Eligibility, Coverage or Benefit Inquiry Information Source Level Loops 2000A and 2100A contain the Information Source Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements that are used to process efficiently through the Anthem East system. 270 Eligibility, Coverage or Benefit Inquiry Detail Information Source Level IG Segment Reference Loop ID 2000A Information Source Level P.41 HL HL01 Information Hierarchical ID Source Level Number Loop ID 2100A Information Source Name P.44 NM1 NM101 Information Entity Identifier Code Source Name NM102 Entity Type Qualifier NM108 Qualifier NM109 (Assigned Positive Number) PR Identifies each specific occurrence of an HL segment within a transaction set. PR - Payer Nonperson Entity PI (Information Source Primary Identifier) Health Care Eligibility, Coverage or Benefit Inquiry Information Receiver Level. PI - Payor Identification Payor Identification number Loop 2100B contains the Information Receiver Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements that are used to process efficiently through the Anthem East system. 270 Eligibility, Coverage or Benefit Inquiry Detail Information Receiver Level IG Segment Reference Loop ID 2100B Information Receiver Name P.50 NM1 NM101 Information Entity Identifier Code Receiver Name NM102 Entity Type Qualifier NM108 Qualifier NM109 P.54 REF REF01 Information Receiver Reference Additional Identification Qualifier Identification REF02 Reference Identification 1P 1P - Provider Person SV XX * (Information Receiver Identification Number) TJ (Information Receiver Additional Identifier) SV - Service Provider Number XX - Health Care Financing Administration NPI Service Provider Number NPI (when XX qualifier used) TJ - Federal Taxpayer's Identification Number Tax ID NOTE. National Provider Identifier Information. *Anthem Blue Cross and Blue Shield has reviewed the requirements of the National Provider Identifier (NPI) as set forth by the Centers for Medicare & Medicaid Services (CMS) and we are in the process of updating our system to accommodate this change. Beginning October 2006 through May 22, 2007, both legacy provider identifiers and NPIs will be accepted. If applicable, please alert your Billing Service, Software vendor, and/or Clearinghouse of this dual receipt time period. Anthem Blue Cross and Blue Shield - East Region Page 6 of 24 Release 04 (June 2006) Version A1 - Oct 2002

7 3 270 Health Care Eligibility, Coverage or Benefit Inquiry Subscriber Level Loops 2100C and 2110C contain the Subscriber Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements, in these Loops that are used to process efficiently through the Anthem East system. IG Segment Reference Loop ID 2000C Subscriber Level P.69 TRN TRN02 Subscriber Reference Trace Identification Number Loop ID 2100C Subscriber Name P.71 NM1 NM103 Subscriber Name Last or Name Organization Name NM104 Name First NM108 Qualifier NM109 P.83 DMG Subscriber Demographic Information P.87 DTP Subscriber Date 270 Eligibility, Coverage or Benefit Inquiry Detail Subscriber Level DMG01 Format Qualifier DMG02 DMG03 Gender Code (Trace Number) (Subscriber Last Name) (Subscriber First Name) MI (Subscriber Primary Identifier) D8 (Subscriber Birth Date) F M DTP01 Date/Time Qualifier Eligibility DTP02 RD8 Format Qualifier DTP03 (Date as Qualified by DTP01, DTP02) Loop ID 2110C Subscriber Eligibility or Benefit Inquiry Information P.106 DTP DTP Eligibility Subscriber Date/Time Qualifier Eligibility/ Benefit Date DTP02 Format Qualifier RD8 DTP03 (Date as Qualified by DTP01, DTP02) This number is provider assigned and necessary for matching of the 271 Response First and Last name of the subscriber as they appear on the Anthem ID card. Anthem East strongly recommends that these fields be populated for positive identification of the subscriber. MI - Member Identification Number Identification number as it appears on the Anthem ID card. Field must be populated for positive identification of the subscriber. D8 - Date Expressed in Format CCYYMMDD Subscriber's date of birth. Anthem East strongly recommends that this field be populated for positive identification of the subscriber. F - female M - male of 'U' (unknown) is not valid RD8 - Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Span of dates in which the provider is requesting confirmation about a patient's eligibility. Anthem East strongly recommends that this field be populated for positive identification of the subscriber. RD8 - Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Span of dates in which the provider is requesting confirmation about a patient's eligibility. Anthem East strongly recommends that this field be populated for positive identification of the subscriber. Anthem Blue Cross and Blue Shield - East Region Page 7 of 24 Release 04 (June 2006) Version A1 - Oct 2002

8 4 270 Health Care Eligibility, Coverage or Benefit Inquiry Dependent Level Loops 2100D and 2110D contain the Dependent Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements, in these Loops that are used to process efficiently through the Anthem East system. IG Segment Reference Loop ID 2000D Dependent Level P.112 TRN TRN02 Subscriber Trace Reference Number Identification Loop ID 2100D Dependent Name P.114 NM1 NM103 Dependent Name Name Last or Organization Name NM104 P.124 DMG Dependent Demographic Information P.129 DTP Dependent Date Name First DMG01 Format Qualifier DMG02 DMG03 Gender Code DTP01 Date/Time Qualifier DTP02 Format Qualifier DTP03 (Trace Number) (Dependent Last Name) (Dependent First Name) D8 (Dependent Birth Date) F M Eligibility RD8 (Date as Qualified by DTP01, DTP02) This number is provider assigned and necessary for matching of the 271 Response First and Last name of the dependent. D8 - Date Expressed in Format CCYYMMDD Dependent's date of birth. Anthem East strongly recommends that this field be populated for positive identification of the dependent as the patient. F - female M - male of 'U' (unknown) is not valid RD8 - Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Span of dates in which the provider is requesting confirmation about a patient's eligibility. Anthem East strongly recommends that this field be populated for positive identification of the dependent as the patient. Loop ID 2110D Dependent Eligibility or Benefit Inquiry Information P.131 EQ EQ Health Benefit Plan Coverage Dependent Eligibility or Benefit Inquiry Information Service Type Code P.145 DTP DTP Eligibility Dependent Eligibility/ Benefit Date 270 Eligibility, Coverage or Benefit Inquiry Detail Dependent Level Date/Time Qualifier DTP02 Format Qualifier DTP03 RD8 (Date as Qualified by DTP01, DTP02) RD8 - Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Span of dates in which the provider is requesting confirmation about a patient's eligibility. Anthem East strongly recommends that this field be populated for positive identification of the dependent as the patient. Anthem Blue Cross and Blue Shield - East Region Page 8 of 24 Release 04 (June 2006) Version A1 - Oct 2002

9 Enveloping This section explains EDI enveloping of the 270 Eligibility, Coverage or Benefit Inquiry that will help you as you submit requests to Anthem East. EDI envelopes control and track communications between you and Anthem East. One envelope may contain many transaction sets grouped into functional groups. The envelope includes the following components: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Anthem Blue Cross and Blue Shield - East Region Page 9 of 24 Release 04 (June 2006) Version A1 - Oct 2002

10 270 Envelope Control Segments Inbound to Anthem East Health Care Eligibility, Coverage or Benefit Inquiry Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. It contains authorization and security information, and it identifies the sender, receiver, date, time, and interchange control number. The following table indicates the specific values of the required header segment and data elements for Anthem East processing. 270 Eligibility, Coverage or Benefit Inquiry Interchange Control Header (ISA) Segment Reference ISA Interchange Control Header ISA01 Authorization Information Qualifier ISA02 Authorization Information ISA03 Security Information Qualifier ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID ISA07 Interchange ID Qualifier ISA08 Interchange Receiver ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Interchange Control Standards Identifier ISA12 Interchange Control Version Number ISA13 Interchange Control Number ISA14 Acknowledgment Requested ISA15 Usage Indicator ISA16 Component Element Separator No Authorization Information Present (10 Spaces) Enter 10 positions No Security Information Present (10 Spaces) Enter 10 positions. (See 270 IG, Appendix B.4) *(Submitter ID) ZZ ANTHEM (YYMMDD) (HHMM) U Qualifier dependent on interchange sender ID selected. *Submitter advises Anthem East on the format of the unique identifier. Anthem East suggests an Anthem Standard Format assigned by your local EDI Business Unit. ZZ - Mutually Defined ANTHEM - Anthem Blue Cross and Blue Shield, East Region Valid date in YYMMDD format. Valid time in HHMM format. U - U.S. EDI Community of ASC X12, TDCC, and UCS Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 (Assigned by Sender) Format - 9 position numeric Unique value greater than zero 0 Anthem East will not respond with TA1 interchange acknowledgment when the interchange is received successfully. P, T Submitter ID must be approved to submit production data. P - Production Data T - Test Data (X) X - 1 character contained in Basic or Extended Character set. must not equal A-Z, a-z, 0-9, "space", and special characters which may appear in text data (i.e., hyphen, comma, period, apostrophe). Anthem Blue Cross and Blue Shield - East Region Page 10 of 24 Release 04 (June 2006) Version A1 - Oct 2002

11 2 270 Health Care Eligibility, Coverage or Benefit Inquiry Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. The following table indicates the specific values of the required header segment and data elements for Anthem East processing. Segment 270 Eligibility, Coverage or Benefit Inquiry Functional Group Header (GS) Reference GS Functional Group Header GS01 Functional Identifier Code GS02 Application Sender's Code GS03 Application Receiver's Code GS04 Date GS05 Time GS06 Group Control Number GS07 Responsible Agency Code GS08 Version / Release / Industry Identifier Code HS HS - Eligibility, Coverage or Benefit Inquiry (270) *(Submitter ID) ANTHEMCT MEDICAIDCT ANTHEMME ANTHEMNH (CCYYMMDD) (HHMM) (Assigned by Sender) X X092A1 *Submitter advises Anthem East on the format of the unique identifier. Anthem East suggests an Anthem Standard Format assigned by your local EDI Business Unit. **Used for batched transactions in separate functional groups Routing to: ANTHEMCT - CT Applications: BCBS, FEP, NASCO MEDICAIDCT - CT Application: BlueCare Family Plan (for claims with DOS prior to 7/1/06) ANTHEMME - ME Applications: BCBS, FEP, NASCO ANTHEMNH - NH Applications: BCBS, FEP, NASCO must be a valid date in CCYYMMDD format. must be a valid time in HHMM format. Format - 1 through 9 positions, numeric ***Unique and not duplicated value greater than zero X - Accredited Standards Committee X12 Operationally used to identify the 270 Eligibility, Coverage or Benefit Inquiry transaction NOTE! Critical Batching and Editing Information. **Transactions must be batched in separate functional group by Application Receiver s Code (GS03). ***Group Control Number (GS06) may not be duplicated by submitter. Files containing duplicate or previously received group control numbers will be rejected. Anthem Blue Cross and Blue Shield - East Region Page 11 of 24 Release 04 (June 2006) Version A1 - Oct 2002

12 3 270 Health Care Eligibility, Coverage or Benefit Inquiry Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. The following table indicates the specific values of the required trailer segment and data elements for Anthem East processing. Segment 270 Eligibility, Coverage or Benefit Inquiry Functional Group Trailer (GE) Reference GE Functional Group Trailer GE01 Number of Transaction Sets Included GE02 Group Control Number (n) Format positions, numeric (Identical to GS06) Format positions, numeric Unique value greater than zero Health Care Eligibility, Coverage or Benefit Inquiry Interchange Control Trailer (IEA) The IEA segment is the ending, outermost level of the interchange control structure. It indicates and verifies the number of functional groups included within the interchange and the interchange control number (the same number indicated in the ISA segment). The following table indicates the specific values of the required trailer segment and data elements for Anthem East processing. Segment 270 Eligibility, Coverage or Benefit Inquiry Interchange Control Trailer (IEA) Reference IEA IEA01 Interchange Number of Included Control Functional Groups Trailer IEA02 Interchange Control Number (n) (Identical to ISA13) Format positions, numeric equal to the number of functional groups (GS/GE pairs) included in the interchange. Format - 9 positions, numeric Unique value greater than zero Anthem Blue Cross and Blue Shield - East Region Page 12 of 24 Release 04 (June 2006) Version A1 - Oct 2002

13 271 Health Care Eligibility, Coverage or Benefit Response Header The 271 Eligibility, Coverage, or Benefit Inquiry Header identifies the start of the transaction, the specific transaction set, and its business purpose. A data element in the header, BHT01 (Hierarchical Structure Code) relates the type of business data expected within each level. The following table indicates the specific values of the required header segment and data elements for Anthem East processing. 271 Eligibility, Coverage or Benefit Information Header IG Segment Reference P.154 ST Transaction Set Header P.156 BHT Beginning of Hierarchical Transaction ST01 Transaction Set ST02 Transaction Set Control Number BHT01 Hierarchical Structure Code BHT02 Transaction Set Purpose Code BHT03 Reference Identification BHT04 Date BHT05 Time Eligibility, Coverage or Benefit Information (Identical to SE02) Unique value Information Source, Information Receiver, Subscriber, Dependent Response (Submitter Transaction Identifier) (Transaction Set Creation Date) (Transaction Set Creation Time) Identifier received on corresponding 270 Date when 271 transaction created Time when 271 transaction created Anthem Blue Cross and Blue Shield - East Region Page 13 of 24 Release 04 (June 2006) Version A1 - Oct 2002

14 271 Health Care Eligibility, Coverage or Benefit Response Detail The 271 Eligibility, Coverage or Benefit Response Detail level contains all data relating to the requested transaction, including transaction participants, the subscriber, the dependent, and the patient detail information. Using a hierarchical level (HL) structure, the four levels for the participant types include: Information Source Level. The Information Source is the payer that maintains the information regarding the patient s coverage. NOTE! Information source does not refer to the entity sending the transaction Information Receiver Level. The Information Receiver is the entity requesting information regarding the patient s coverage and is typically the medical service provider verifying insurance coverage for the patient. Subscriber Level. The subscriber who may or may not be the patient, is uniquely identified to an Information Source, traditionally referred to as a member. Dependent Level. The dependent who may or may not be the patient, is related to the subscriber. Anthem Blue Cross and Blue Shield - East Region Page 14 of 24 Release 04 (June 2006) Version A1 - Oct 2002

15 1 271 Health Care Eligibility, Coverage or Benefit Response Information Source Level Loops 2000A and 2100A contain the Information Source Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements that are used to process efficiently through the Anthem East system. IG Segment Reference Loop ID 2000A Information Source Level P.160 AAA AAA01 Request Yes/No Condition or Validation Response Code AAA03 Reject Reason Code AAA04 Follow-up Action Code Loop ID 2100A Information Source Name P.163 NM1 NM101 Information Entity Identifier Code Source Name NM102 Entity Type Qualifier NM103 Name Last or Organization Name NM108 Qualifier NM109 (Valid Request Indicator) (Assigned by Issuer) (Recipient Instruction) PR Indicates that the request 270 was rejected Indicates the reason why the transaction was not processed successfully Indicates what further action needs to be taken PR - Payer Non- Person Entity Anthem Blue Cross and Blue Shield PI Name of organization, information source PI - Payor Identification (Information Source Anthem East identification number Primary Identifier) PER segment applies to Anthem East (CT, ME) only P.168 PER Administrative PER02 Name Access IT Information Source Contact Name Communications Contact P.172 AAA Request Validation 271 Eligibility, Coverage or Benefit Information Detail Information Source Level PER03 Communication Number Qualifier PER04 Communication Number AAA01 Yes/No Condition or Response Code AAA03 Reject Reason Code AAA04 Follow-up Action Code TE (1-888-ANTHEM) (Valid Request Indicator) (Assigned by Issuer) (Recipient Instruction) TE - Telephone Information Source Communication Number Indicates that the request 270 was rejected Indicates the reason why the transaction was not processed successfully Indicates what further action needs to be taken Anthem Blue Cross and Blue Shield - East Region Page 15 of 24 Release 04 (June 2006) Version A1 - Oct 2002

16 2 271 Health Care Eligibility, Coverage or Benefit Response Information Receiver Level Loop 2100B contains the Information Receiver Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements that are used to process efficiently through the Anthem East system. IG Segment Reference Loop ID 2100B Information Receiver Name P.178 NM1 NM101 1P 1P - Provider Information Entity Identifier Code Receiver Name NM Person Entity Type Qualifier NM103 Name Last or Organization Name (Information Receiver Last or Organization Name) Name of organization, information receiver P.182 REF Information Receiver Additional Identification P.184 AAA Information Receiver 271 Eligibility, Coverage or Benefit Information Detail Information Receiver Level NM108 Qualifier NM109 REF01 Reference Identification Qualifier REF02 Reference Identification AAA01 Yes/No Condition or Response Code Request Validation AAA03 Reject Reason Code AAA04 Follow-up Action Code SV XX * (Information Receiver Identification Number) TJ (Information Receiver Additional Identifier) (Valid Request Indicator) (Assigned by Issuer) (Recipient Instruction) SV - Service Provider Number XX - Health Care Financing Administration NPI Service Provider Number NPI (when XX qualifier used) TJ - Federal Taxpayer's Identification Number Tax ID Indicates that the request 270 was rejected Indicates the reason why the transaction was not processed successfully Indicates what further action needs to be taken NOTE. National Provider Identifier Information. *Anthem Blue Cross and Blue Shield has reviewed the requirements of the National Provider Identifier (NPI) as set forth by the Centers for Medicare & Medicaid Services (CMS) and we are in the process of updating our system to accommodate this change. Beginning October 2006 through May 22, 2007, both legacy provider identifiers and NPIs will be accepted. If applicable, please alert your Billing Service, Software vendor, and/or Clearinghouse of this dual receipt time period. Anthem Blue Cross and Blue Shield - East Region Page 16 of 24 Release 04 (June 2006) Version A1 - Oct 2002

17 3 271 Health Care Eligibility, Coverage or Benefit Response Subscriber Level Loops 2000C, 2100C, and 2110C contain the Subscriber Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements that are used to process efficiently through the Anthem East system. IG Segment Reference Loop ID 2000C Subscriber Level P.187 HL Subscriber HL01 Hierarchical ID Number (Assigned by Sender) Identifies each specific occurrence of an HL segment within a transaction set. Level HL02 Hierarchical Parent ID Number See 271 IG Page 188 Identifies the specific hierarchical level to which this level is subordinate. HL04 Hierarchical Child Code Loop ID 2100C Subscriber Name P.193 NM1 NM103 Subscriber Name Last or Organization Name Name NM104 Name First NM108 Qualifier NM109 P.196 REF Subscriber Additional Identification P.207 AAA Subscriber Request Validation P.210 DMG Subscriber Demographic Information P.212 INS Subscriber Relationship 271 Eligibility, Coverage or Benefit Information Detail Subscriber Level REF01 Reference Identification Code Qualifier REF02 Reference Identification AAA01 Yes/No Condition or Response Code AAA03 Reject Reason Code AAA04 Follow-up Action Code DMG01 Format Qualifier DMG02 INS01 Yes/No Condition or Response Code INS02 Individual Relationship Code See 271 IG Page 189 (Subscriber Last Name) (Subscriber First Name) MI (Subscriber Primary Identifier) 6P (Subscriber Supplemental Identifier) (Valid Request Indicator) (Assigned by Issuer) (Recipient Instruction) D8 (Subscriber Birth Date) Y Indicates additional hierarchical levels subordinate to the current hierarchical level. First and Last name of the subscriber as it appears on the Anthem ID card MI - Member Identification Number Identification number as it appears on the Anthem ID card 6P - Group Number Identifies the employer group through which the member obtains health coverage Indicates that the request 270 was rejected Indicates the reason why the transaction was not processed Indicates what further action needs to be taken D8 - Date Expressed in Format CCYYMMDD Subscriber's date of birth Y - Yes Self Anthem Blue Cross and Blue Shield - East Region Page 17 of 24 Release 04 (June 2006) Version A1 - Oct 2002

18 271 Eligibility, Coverage or Benefit Information Detail Subscriber Level IG Segment Reference Loop ID 2110C Subscriber Eligibility or Benefit Information P.218 EB EB03 (Service Category) Classifies the type of service Subscriber Service Type Code Eligibility or Benefit (Free-Text Form) Information EB05 Plan Coverage Description Describes the plan, identifies the specific product name for an insurance plan Applies to Anthem East (CT, ME only) DTP segment applies to Anthem East (CT, ME) only P.240 DTP DTP Eligibility Subscriber Date/Time Qualifier Eligibility/Benefit Date DTP02 RD8 RD8 - Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Format Qualifier DTP03 P.242 AAA Subscriber Request Validation AAA01 Yes/No Condition or Response Code AAA03 Reject Reason Code AAA04 Follow-up Action Code (Eligibility or Benefit Date Time Period) (Valid Request Indicator) (Assigned by Issuer) (Recipient Instruction) Span of dates in which the provider is requesting confirmation about a patient's eligibility. Anthem East strongly recommends that this field be populated for positive identification of the subscriber. Indicates that the request 270 was rejected Indicates the reason why the transaction was not processed successfully Indicates what further action needs to be taken Anthem Blue Cross and Blue Shield - East Region Page 18 of 24 Release 04 (June 2006) Version A1 - Oct 2002

19 4 271 Health Care Eligibility, Coverage or Benefit Response Dependent Level Loops 2000D, 2100D, and 2110D contain the Dependent Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements, in these Loops that are used to process efficiently through the Anthem East system. IG Segment Reference Loop ID 2000D Dependent Level P.265 HL HL01 Dependent Level Hierarchical ID Number HL02 Hierarchical Parent ID Number HL04 Hierarchical Child Code Loop ID 2100D Dependent Name P.271 NM1 NM103 Dependent Name Name Last or Organization Name NM104 Name First NM108 Qualifier NM109 P.274 REF Dependent Additional Identification P.284 AAA Dependent Request Validation P.287 DMG Dependent Demographic Information P.289 INS Dependent Relationship 271 Eligibility, Coverage or Benefit Information Detail Dependent Level REF01 Reference Identification Code Qualifier REF02 Reference Identification AAA01 Yes/No Condition or Response Code AAA03 Reject Reason Code AAA04 Follow-up Action Code DMG01 Format Qualifier DMG02 INS01 Yes/No Condition or Response Code INS02 Individual Relationship Code (Assigned by Sender) See 271 IG Page 266 See 271 IG Page 267 (Dependent Last Name) (Dependent First Name) MI (Dependent Primary 6P (Dependent Supplemental Identifier) (Valid Request Indicator) (Assigned by Issuer) (Recipient Instruction) D8 (Dependent Birth Date) N (Relationship) Identifies each specific occurrence of an HL segment within a transaction set. Identifies the specific hierarchical level to which this level is subordinate. Indicates additional hierarchical levels subordinate to the current hierarchical level. First and Last name of the dependent MI - Member Identification Number Identification number as it appears on the Anthem ID card 6P - Group Number Identifies the employer group through which the dependent obtains health coverage Indicates that the request 270 was rejected Indicates the reason why the transaction was not processed successfully Indicates what further action needs to be taken D8 - Date Expressed in Format CCYYMMDD Dependent's date of birth N - No Indicates the relationship between the dependent and subscriber Anthem Blue Cross and Blue Shield - East Region Page 19 of 24 Release 04 (June 2006) Version A1 - Oct 2002

20 271 Eligibility, Coverage or Benefit Information Detail Dependent Level IG Segment Reference Loop ID 2110D Dependent Eligibility or Benefit Information P.295 EB EB01 See 271 IG Dependent Eligibility or Benefit Page 296 Eligibility or Information Benefit Information EB03 See 271 IG Service Type Code Page 298 EB05 (Free-form Text) Plan Coverage Description DTP segment applies to Anthem East (CT, ME) only P.316 DTP DTP01 Dependent Eligibility/Benefit Date Identifies eligibility or benefit information Classifies the type of service Eligibility Date/Time Qualifier DTP02 RD8 Format Qualifier DTP03 (Eligibility or Benefit Date Time Period) P.318 AAA AAA01 (Valid Request Subscriber Yes/No Condition or Indicator) Request Validation Response Code AAA03 Reject Reason Code AAA04 Follow-up Action Code (Assigned by Issuer) (Recipient Instruction) Describes the plan, identifies the specific product name for an insurance plan RD8 - Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Span of dates in which the provider is requesting confirmation about a patient's eligibility. Anthem East strongly recommends that this field be populated for positive identification of the subscriber. Indicates that the 270 request transaction was rejected. Indicates the reason why the transaction was not processed successfully. Indicates what further action needs to be taken. Anthem Blue Cross and Blue Shield - East Region Page 20 of 24 Release 04 (June 2006) Version A1 - Oct 2002

21 Enveloping This section explains EDI enveloping of the 271 Eligibility, Coverage or Benefit Response transaction. EDI envelopes control and track communications between you and Anthem East. One envelope may contain many transaction sets grouped into functional groups. The envelope includes the following components: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Anthem Blue Cross and Blue Shield - East Region Page 21 of 24 Release 04 (June 2006) Version A1 - Oct 2002

22 271 Envelope Control Segments Outbound from Anthem East Health Care Eligibility, Coverage or Benefit Response Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. It contains authorization and security information, and it identifies the sender, receiver, date, time, and interchange control number. The following table indicates the specific values of the required header segment and data elements for Anthem East processing. 271 Eligibility, Coverage or Benefit Information Interchange Control Header (ISA) Segment Reference ISA Interchange Control Header ISA01 Authorization Information Qualifier ISA02 Authorization Information ISA03 Security Information Qualifier ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID ISA07 Interchange ID Qualifier ISA08 Interchange Receiver ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Interchange Control Standards Identifier ISA12 Interchange Control Version Number ISA13 Interchange Control Number ISA14 Acknowledgment Requested ISA15 Usage Indicator ISA16 Component Element Separator No Authorization Information Present (10 Spaces) 10 position value populated on 270 transaction No Security Information Present (10 Spaces) 10 position value populated on 270 transaction. ZZ ANTHEM ZZ (Receiver ID) (YYMMDD) (HHMM) U ZZ - Mutually Defined ANTHEM - Anthem Blue Cross and Blue Shield, East Region ZZ - Mutually Defined Submitter ID populated on 270 transaction. Valid date in YYMMDD format. Valid time in HHMM format. U - U.S. EDI Community of ASC X12, TDCC, and UCS Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 (Assigned by 9 position numeric value; unique and greater than zero. Anthem) 0 Anthem East will not respond with TA1 interchange acknowledgment when the interchange is received successfully. P, T Submitter ID must be approved to submit production data. P - Production Data T - Test Data (X) X - 1 character contained in Basic or Extended Character set. not equal A-Z, a-z, 0-9, "space", and special characters which may appear in text data (i.e., hyphen, comma, period, apostrophe). Anthem Blue Cross and Blue Shield - East Region Page 22 of 24 Release 04 (June 2006) Version A1 - Oct 2002

23 2 271 Health Care Eligibility, Coverage or Benefit Response Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. The following table indicates the specific values of the required header segment and data elements for Anthem East processing. Segment GS Functional Group Header 271 Health Care Eligibility, Coverage or Benefit Information Functional Group Header (GS) Reference GS01 Functional Identifier Code GS02 Application Sender's Code GS03 Application Receiver's Code GS04 Date GS05 Time GS06 Group Control Number GS07 Responsible Agency Code GS08 Version / Release / Industry Identifier Code HB HB - Eligibility, Coverage or Benefit Information (271) ANTHEMCT MEDICAIDCT ANTHEMME ANTHEMNH *(Receiver ID) (CCYYMMDD) (HHMM) (Assigned by Anthem) X X092A1 Used for batched transactions in separate functional groups Routing to: ANTHEMCT - CT Applications: BCBS, FEP, NASCO MEDICAIDCT - CT Application: BlueCare Family Plan (for claims with DOS prior to 7/1/06) ANTHEMME - ME Applications: BCBS, FEP, NASCO ANTHEMNH - NH Applications: BCBS, FEP, NASCO *Submitter ID used on 270 transaction. Submitter advises Anthem East on the format of the unique identifier. Anthem East suggests an Anthem Standard Format assigned by your local EDI Business Unit. Valid date in CCYYMMDD format. Valid time in HHMM format. Format - 1 through 9 positions, numeric Unique and not duplicated value greater than zero X - Accredited Standards Committee X12 Operationally used to identify the 271 Eligibility, Coverage or Benefit Information transaction NOTE! Anthem assigns a new, unique GS Control Number to the 271 transaction. Since the original submitted GS Control Number on the 270 transaction is not used, the TRN number is used to match the 271 response to the 270 request. Anthem Blue Cross and Blue Shield - East Region Page 23 of 24 Release 04 (June 2006) Version A1 - Oct 2002

24 3 271 Health Care Eligibility, Coverage or Benefit Response Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. The following table indicates the specific values of the required trailer segment and data elements for Anthem East processing. Segment 271 Eligibility, Coverage or Benefit Information Functional Group Trailer (GE) Reference GE Functional Group Trailer GE01 Number of Transaction Sets Included GE02 Group Control Number (n) Format positions, numeric (Identical to GS06) Format positions, numeric Unique value greater than zero Health Care Eligibility, Coverage or Benefit Response Interchange Control Trailer (IEA) The IEA segment is the ending, outermost level of the interchange control structure. It indicates and verifies the number of functional groups included within the interchange and the interchange control number (the same number indicated in the ISA segment). The following table indicates the specific values of the required trailer segment and data elements for Anthem East processing. Segment 271 Eligibility, Coverage or Benefit Information Interchange Control Trailer (IEA) Reference IEA Interchange Control Trailer IEA01 Number of Included Functional Groups IEA02 Interchange Control Number (n) (Identical to ISA13) Format positions, numeric equal to the number of functional groups (GS/GE pairs) included in the interchange. Format - 9 positions, numeric Unique value greater than zero Anthem Blue Cross and Blue Shield - East Region Page 24 of 24 Release 04 (June 2006) Version A1 - Oct 2002