I'd like to add one other thought to what David has provided on the 271
transaction. I co-chair the X12N Eligibility WG responsible for the 270
and 271 transactions. These transactions were set up to provide several
different types of information exchanges.
1. An inquiry and response exchange, where a provider/payer/employer could
query a health plan to determine what health benefits are available to a
specific member. The party making the inquiry should have a valid reason
for asking, such as, they are a provider about to provide services to the
member, or they are a health plan that may be party to COB, or they are the
members employer and they wish to verify that all benefits have been
properly assigned.
2. Eligibility inquiries can be accommodated in both batch or real-time
fashion as described in the implementation guide. Basically, real-time
transactions are limited to one inquiry about one member. Real-time
inquiries must be responded to within a 60 second window of time, or sooner
if possible. While batch inquiries can be about multiple members and are
typically responded to on a scheduled basis, but no less than once per day.
3. The 271 transactions can also be sent in what we refer to as
unsolicited mode, meaning there was no corresponding 270 transaction.
These are usually sent in batch form by a health plan to capitated
providers. The purpose is to inform a provider that they have
responsibility to provide services to a list of members who have selected
them as their PCP or Specialist or Servicing Facility (e.g., a hospital or
clinic). These rosters when sent to a provider can also be used in
coordination with the 835 transaction for capitated payments, where the 271
would serve as the detail for what they were being paid. Rosters have many
different forms, they can be a list of plan sponsors, a list of members
within a plan sponsor, and/or a list of benefits associated with a health
plan for a particular plan sponsor. A separate implementation guide for
the 271 Roster transaction has been written, but it has not been officially
published as a HIPAA transaction. It is our hope that DHHS will adopt the
271 Roster Transaction as a HIPAA transaction for communicating Roster
information to Providers and Employers. However, a request to have this
occur has not yet been submitted.
Don Bechtel
"David A. Feinberg, C.D.P." <[EMAIL PROTECTED]>@wedi.org on 08/17/2001
06:41:48 PM
Please respond to <[EMAIL PROTECTED]>
Sent by: [EMAIL PROTECTED]
To: <[EMAIL PROTECTED]>, <[EMAIL PROTECTED]>
cc: "Siegfried, Victoria" <[EMAIL PROTECTED]>
Subject: Re: Purpose of 271 transaction
Greetings Vicki,
First of all, to answer your original questions:
* Is the 271 transaction intended to cover routine eligibility
extracts or rosters?
= The "transaction" is intended to cover both plus more.
Note the key distinction between a transaction and an
Implementation Guide; which I've further explained a bit
below.
* Is a 271 transaction only generated in response to a 270
transaction?
= In general, No; for HIPAA, Yes. Again see the explanation
that follows.
X12 transaction standards (e.g., 271, 837, 835) are intended to be as
encompassing as possible to the widest possible variations of business
needs for Electronic Data Interchange (EDI). As such, they have lots
of optional fields and uses. Which of these optional fields are
populated and with what contents are historically determined by
'trading partner agreements'. Trading partner agreements are usually
quite specific to the organization pairs actually exchanging
information on a situation-by-situation basis. Thus, uses of the X12
transaction standards can vary considerably; with all such uses being
'standard compliant'.
The X12N Implementation Guides are intended to constrain the use of
the X12 transaction standards to a single set of fields and contents
for each transaction: both HIPAA and non-HIPAA. Thus, for example,
there are three Implementation Guides (X098, X096, X097) which define
three different uses of X12 transaction standard 837 for the purposes
of transmitting claims (professional, institutional, dental). In
particular response to your queries, the Implementation Guide (X092)
for Eligibility specifies that a 271 transaction is used in response
to a 270 query. This Implementation Guide has also been adopted for
use under HIPAA.
Thus, the 271 transaction standard may be used in many ways, but if
you're attempting purely HIPAA compliance, then you must follow the
HIPAA Implementation Guides; which thus far only specify the use of
the 271 in response to a 270. As an example of a use of the 271 in
support of a roster, take a look at Implementation Guide X040 -- which
is not [yet] HIPAA.
There are a few more small points that could be made, but I hope the
above is enough to provide the answers you requested along with some
background. Do keep asking as other issues arise in the ever
fascinating :-) world of HIPAA and EDI.
Dave Feinberg
Co-Chair, HIPAA Implementation Work Group
Insurance Subcommittee (X12N)
Accredited Standards Committee X12
Voting Member, HL7 and X12
Rensis Corporation [A Consulting Company]
206-617-1717
[EMAIL PROTECTED]
----- Original Message -----
From: "Siegfried, Victoria" <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Cc: <[EMAIL PROTECTED]>
Sent: Friday, August 17, 2001 11:47 AM
Subject: Purpose of 271 transaction
I have 2 basic questions on the purpose and use of the 271 transaction
that
I have not seen specifically addressed in the implementation guide:
* Is the 271 transaction is intended to cover routine eligibility
extracts or rosters?
* Is a 271 transaction only generated in response to a 270
transaction?
Vicki Siegfried
Business Consultant
Coventry Health Care
HIPAA / EDI Team
(724) 778-5931
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