United Nations Directories for Electronic Data Interchange for
Administration, Commerce and Transport
UN/EDIFACT
United Nations Directories for Electronic Data Interchange for |
Message Type : IHCLME
Version : D
Release : 01C
Contr. Agency: UN
Revision : 1
Date : 2001-11-07
SOURCE: D11 Healthcare (SWG)
CONTENTS
Health care claim or encounter request and response - interactive
message
0. INTRODUCTION
1. SCOPE
1.1 Functional definition
1.2 Field of application
1.3 Principles
2. REFERENCES
3. TERMS AND DEFINITIONS
3.1 Standard terms and definitions
4. MESSAGE DEFINITION
4.1 Segment clarification
4.2 Segment index (alphabetical sequence by tag)
4.3 Message structure
4.3.1 Segment table
----------------------------------------------------------------------
For general information on UN standard message types see UN Trade Data
Interchange Directory, UNTDID, Part 4, Section 2.3, UN/ECE UNSM
General Introduction
----------------------------------------------------------------------
0. INTRODUCTION
This specification provides the definition of the Health care
claim or encounter request and response - interactive message
(IHCLME) to be used in Electronic Data Interchange (EDI)
between trading partners involved in administration, commerce
and transport.
1. SCOPE
1.1 Functional definition
This message is to support interactive submittal and response
of health care claims or encounters for the point of sale
environment.
It will be used in health care information scenarios when
immediate response is appropriate.
1.2 Field of application
The Health care claim or encounter request and response -
interactive message may be used for both national and
international applications. It is based on universal practice
related to administration, commerce and transport, and is not
dependent on the type of business or industry.
1.3 Principles
This message establishes the data contents of the IHCLME.
This can be used to create interactive communications between
health care providers (e.g., physicians, hospitals, other
medical facilities, dentists, etc.), health care information
processors, health care payers, and/or their agents. The
information includes, but is not limited to, billing
information (for full or partial adjudication), encounter
reporting, additional service information (denial reasons,
errors, pending data, etc.), and coordination of benefits.
IHCLME may be used for the following functions within the claim
or encounter scenario for health care:
(1) To request and respond to a request for processing a claim
or encounter episode.
(2) To request and respond to a request to modify or cancel a
previously submitted claim or encounter.
(3) To request and respond to a pre-determination of benefits
as it relates to a covered life.
(4) To request and respond to a need for additional information
as it relates to a claim or encounter episode.
An example of health care processors or their agents includes:
- Insurance Companies
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Health Care Purchasers (e.g., employers)
- Professional Review Organizations (PROs)
- Social Worker Organizations
- Health Care Providers (e.g., physicians, hospitals,
laboratories)
- Third Party Administrators (TPAs)
- Health Care Vendors (e.g., practice management vendors,
billing services)
- Service Bureaus (value added networks or value added banks)
- Government agencies such as Medicare, Medicaid and Civilian
Health and Medical Program of the Uniformed Services
(CHAMPUS).
2. REFERENCES
See UNTDID, Part 4, Chapter 2.3 UN/ECE UNSM - General
Introduction, Section 1.
3. TERMS AND DEFINITIONS
3.1 Standard terms and definitions
See UNTDID, Part 4, Chapter 2.3 UN/ECE UNSM - General
Introduction, Section 2.
4. MESSAGE DEFINITION
4.1 Segment clarification
This section should be read in conjunction with the segment
table which indicates mandatory, conditional and repeating
requirements.
0010 UIH, Interactive message header
A service segment starting and uniquely identifying a message.
The message type code for the Health care claim or encounter
request and response - interactive message is IHCLME.
Note: Health care claim or encounter request and response -
interactive messages conforming to this document must contain
the following data in segment UIH, composite S306:
Data element 0065 IHCLME
0052 D
0054 01C
0051 UN
0020 MSD, Message action details
To specify the message processing requirements, response type,
and to provide a tracking mechanism. The reference number in
this segment will provide for a different tracking number than
what is generated in the message envelope, for application
level tracking.
0030 PRT, Party information
To provide specific identification numbers and demographic
information regarding the identity of the participating
parties. Date of birth, eligibility date, and date of death may
be specified as well as relationship between the patient and
the insured, sex, employment category, marital status, student
status, and a yes or no indication of whether the patient is
pregnant.
0040 NAA, Name and address
To specify a party identity, and, when necessary, the name
and/or the address in either a structured or unstructured
format. For use in health care, it is recommended to use only
the identification, but if the name or address are needed, to
use only the structured method of submittal.
0050 CON, Contact information
To provide electronic message routing information for
additional recipients of this message. The reference number
will provide a unique reference number to be used by the
contact entity when referring to this message.
0060 BLI, Billable information
To provide summarized information about all services covered
under one health care claim or encounter. This segment allows
detail relating to monetary amounts for the total amount being
charged for the claim, total amount that the patient has paid,
and the total amount paid by other benefit carriers. Multiple
diagnoses that apply to the entire claim, and multiple dates
may be conveyed. The plan sponsor can receive the reference of
any pre-authorization information associated with the claim and
through a series of yes and no indications will know whether
the provider accepts the insurance payment as payment in full,
and whether the patient has signed documents releasing the
medical information to the insurance carrier and authorizing
the payment directly to the provider. The presence, nature,
date, and state or province of a cause related to this claim,
such as an accident, may also be indicated.
0070 ITC, Institutional claim
To provide specific claim information only needed when
processing claims for services performed while admitted to a
health care institution. When the claim is generated from a
health care institution, additional information such as the
type (e.g. first, intermediate, last) and frequency of
invoicing during an extended admission, the number of days
covered and non covered by insurance, the type (e.g. emergency,
scheduled) and source of admission, the discharge type (e.g.
ambulatory, transfer, dead), and information about other
products and services related to the institutional admission
may be needed.
0080 ADI, Health care claim adjudication information
To provide adjudication information for all services, supplies
or products in the health care claim. The internal control
number assigned by the payer, the specific service trace or
sequence number designated for this service in the original
claim, the payment or draft control number, the health care
service being paid, the health case service originally billed,
the health care service institutional "revenue" code, the
notification of the adjudication action taken by the payer, the
total amount paid, other informational amounts (e.g negotiated
discount), the number of services adjudicated, the number of
services originally billed, the importance given to the
diagnosis related group in calculating the payment, the
financial adjustments (e.g. deductible, agreed fee limit) made
in the adjudication, identification of health care policy
limitations, the insurance product group (e.g. indemnity,
managed care, federal program), the anticipated date of
payment, the diagnosis category from a diagnosis related
grouping program, and the percentage known as "discharge
fraction" may all be sent in this segment.
0090 FRM, Follow-up action
To identify specific corrective actions that should occur
before the adjudication process can complete. The identity
number in this segment must be one of the identity number given
in an ADI segment. The follow-up actions may be for the entire
claim or may be service specific.
0100 Segment group 1: OTI-NAA
A group of segments to identify all parties by code and name
that may provide insurance coverage for the patient being
treated.
0110 OTI, Other insurance
To provide payer, insured and payment information when
benefits are being coordinated between third party benefit
carriers. A major source of concern in health care is being
able to coordinate benefits between multiple insurance
carriers. This segment will be used to reference other
payers that may need to be kept abreast of the health care
transaction and what monetary amounts are being paid by the
respective carrier. Even though three different carriers may
be identified, there is a yes or no indicator that will
allow the indication of additional carriers beyond what is
being sent.
0120 NAA, Name and address
To specify identification numbers, name and address
information relating to the other insurance parties. If
available, the identification number of the insurance
carrier should be used. When the identification number is
not available, or the insurance carrier operates out of
multiple offices, the name and/or address should be used.
0130 Segment group 2: PSI-DNT
To identify the specific service information for the claim or
encounter.
0140 PSI, Service information
To provide detail information about the service, product, or
procedure. This segment allows the payer of a health care
transaction to indicate line item detail about all services
performed. All charges can be broken down, several of the
diagnosis codes from the claim can be references with an
index identifier, and any supporting evidence and out of
band additional information needed for the claim can be
referenced.
0150 DNT, Dental information
To provide specific a complete description of each tooth in
relation to the service. Only in a dental claim, would the
payer need to know specific tooth and additional information
on the surface, gum depth or status.
0160 UIT, Interactive message trailer
A service segment ending a message, giving the total number of
segments in the message (including the UIH & UIT) and the
control reference number of the message.
4.2 Segment index (alphabetical sequence by tag)
ADI Health care claim adjudication information
BLI Billable information
CON Contact information
DNT Dental information
FRM Follow-up action
ITC Institutional claim
MSD Message action details
NAA Name and address
OTI Other insurance
PRT Party information
PSI Service information
UIH Interactive message header
UIT Interactive message trailer
4.3 Message structure
4.3.1 Segment table
Pos Tag Name S R
0010 UIH Interactive message header M 1
0020 MSD Message action details C 1
0030 PRT Party information C 9
0040 NAA Name and address C 9
0050 CON Contact information C 9
0060 BLI Billable information C 1
0070 ITC Institutional claim C 1
0080 ADI Health care claim adjudication
information C 99
0090 FRM Follow-up action C 99
0100 ----- Segment group 1 ------------------ C 3-----------+
0110 OTI Other insurance M 1 |
0120 NAA Name and address C 2-----------+
0130 ----- Segment group 2 ------------------ C 99----------+
0140 PSI Service information M 1 |
0150 DNT Dental information C 35----------+
0160 UIT Interactive message trailer M 1
Copyright United Nations, all rights reserved
UN Economic Commission for Europe
Palais des Nations, CH-1211 Geneva 10, Switzerland
Tel: +41-22 917 2016 Fax: +41-22 917 0037 E-mail: TradeMaster@unece.org
UN/EDIFACT Directories