United Nations Directories
for Electronic Data Interchange for
Administration, Commerce and Transport



 UN/EDIFACT

Message Type : IHCEBI Version : D Release : 09B Contr. Agency: UN Revision : 1 Date : 2010-01-19 SOURCE: TBG10 Healthcare CONTENTS Interactive health insurance eligibility and benefits inquiry and response 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 3.2 Message 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 Interactive health insurance eligibility and benefits inquiry and response (IHCEBI) to be used in Electronic Data Interchange (EDI) between trading partners involved in administration, commerce and transport. 1. SCOPE The Interactive health insurance eligibility benefit inquiry and response message may be used for both national and international applications. It is based on universal practices related to administration, commerce and transport, and is not dependent on the type of business or industry. In particular, IHCEBI can be applied to all types of health care service providers, funding institutions and health care delivery systems. 1.1 Functional definition The IHCEBI message is sent from institutional or individual health care providers or those providing related administrative services to a funding institution to obtain health insurance information from a patientís health plan prior to or at the time of admission or treatment. This inquiry message will allow a health care provider to give their patient an estimate of cost for certain treatments, or assess their own financial risk associated with certain treatments, and provide the patient with informed financial choices regarding their health care options. Each inquiry can provide information to the health plan about a service being considered, (e.g., actual or expected service dates, actual or expected duration of hospital stay, and planned services). An inquiry can also contain information about the treating and referring practitioner, if they are not the health care party making the inquiry. The response message will provide information regarding what benefits are available to the patient based on their health plan contract and the information provided with the inquiry. This can include financial information, such as, co-pay amounts, deductible amounts, limitations, and exclusions. Each response can also provide information regarding administrative issues concerning a covered benefit, such as, indicate who is the primary provider for a service, contact information for the health plan and patient, and policy rules, such as, certain screening exams can only be done once every two years. 1.2 Field of application The Interactive health insurance eligibility and benefits inquiry and response 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 The IHCEBI message can carry either an initial inquiry, modifications to an inquiry made in a previous eligibility request and response message from the funding institution. An inquiry can only concern one patient or health plan subscriber, but may concern one or more services or procedures regarding an individual patient or subscriber. A response is limited to providing an answer to the questions asked about a patient or health plan subscriber, but may report benefits for multiple family members. 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. 3.2 Message terms and definitions Capitated provider - is a term that describes a provider who is under contract with a health plan and the provider agrees to receive a monthly capitation payment amount per patient each month in lieu of fee for service payment or charges. Under this arrangement a provider cannot charge for services rendered that are described in their contract, for example, routine well visits or sick visits. 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 Interactive health insurance eligibility and benefits inquiry and response is IHCEBI. Note: Interactive health insurance eligibility and benefits inquiry and responses conforming to this document must contain the following data in segment UIH, composite S306: Data element 0065 IHCEBI 0052 D 0054 09B 0051 UN 0020 MSD, Message action details Use to specify the message and processing requirements, for example, the type of health care insurance verification to be done and to provide a tracking mechanism for the submitter of the message. The reference number in this segment will provide an application level tracking number, which is different from what is generated in the message envelope. 0030 Segment group 1: PRT-NAA-CON-FRM Associated Parties Group: A group of segments that will be repeated once for each party involved with this eligibility message, used to identify and provide information about each party by code and name. Parties may include and a loop would be present for: 1) Submitter - when serving as an agent for the provider, 2) Requester - either a provider, payer, or employer making a request, 3) Responder - either a payer or a third party administrator when serving as an agent for the payer, 4) Subscriber - will always be present, and 5) Patient - present only when patient is not the subscriber. In the response message the responder may optionally add one or more entries to this loop to identify a patient's primary care physician (PCP) or specialist, if the provider making the inquiry is not the patient's PCP or specialist. Other parties may also be added to identify other capitated providers associated with the patient care and health plan.