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 D B UN
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.
To provide specific entity identifiers or demographic information regarding the identity of the participating parties. For individuals identifiers will include date of birth, or a health plan insurance card date of issue as shown on the card may be specified in this segment, when the segment is identifying a health plan subscriber.
Use to specify a party identity, and when necessary, the name and address of an entity and their related function in either a structured or unstructured format. For use in health care, it is recommended to use only the name and identifier, but when name and address are required use only the structured method of submittal. This segment is providing the name and address of the party identified in the Associated Parties Group.
Use to specify contact communication numbers, names, and electronic message routing information. Use to provide information about contacts within an organization or associated with the party identified in the Associated Parties Loop who can be called upon for further or clarifying information. The reference number may be used to provide a unique number for the contact entity to use when referring to this message.
Used only with the response message, this will identify specific corrective actions or follow-up that should occur before another inquiry is made about this entity. Errors reported here related to the parties identified in the Associated Parties Group. For example, provider is not authorised to inquire against this payer's files.
Use to specify dates that will common to each benefit or covered service. On the request message, this segment will be used to specify the service or planned service dates for the benefits in question. On the response message, this segment will specify the effective dates of benefit coverage for all listed benefits. The information in this segment can be overridden for a specific benefit, when effective or termination dates are different from the overall plan. This is done in the Health Insurance Benefit Details Group for each reported benefit where it applies.
To identify specific corrective actions or follow-up that should occur before another inquiry is made about the patient in the request message. This segment is only sent with the response message when there are errors to report related to the benefit information request message within the Global Benefit and Service Coverage Group. For example, an invalid service date or insurance type was specified.
Use to specify specific benefits and associated coverage. When used on the request message, it will specify a specific benefit or covered service in question. When used on the response, it will provide information about the requested health insurance benefits and coverage available, plus any additional administrative information that may have a business or patient care impact to the party making the inquiry.
Use to specify diagnosis information and procedure or therapy services and details about how and when these services can be delivered, based on the diagnosis or procedure or contract terms or all of these. When this information is sent on the request, it is describing the diagnosis of the patient and asking about benefit coverage for a specific procedure or therapy. When the information is sent on the response, it is providing information from the health insurance plan about what benefit coverage is available, for certain procedures based on the diagnosis and what service delivery requirements exist, which can vary based on diagnosis, procedure, and health plan contract.
Use to specify eligibility dates related to the benefit or service described in the current iteration of the Health Insurance Benefit Details Group. When used at this level on the request message, it is to specify service dates from the provider that are outside of the service dates specified in the Global Benefit Service Details Group. When used at this level on the response message it identifies eligibility start or termination dates assigned by the responder that override the overall eligibility dates identified in the earlier Global Benefit Service Details Group.
Use to reference a specific payer or provider for the benefit or service identified in the current Health Insurance Benefit Details Group. The payer or provider should be in the list of parties identified within the Associated Parties Group, where full details of the entity should be provided, including name, address, and contact information. The payer is most likely used for third party liability for coordination of benefits. Identified providers would be those restricted to providing services for the identified benefit, for example, a capitated provider.
Use to identify specific corrective actions or follow-up that should occur before another inquiry is made about this subject entity, that is, the patient or health plan subscriber. Errors reported at this level of the message are benefit specific, reporting processing errors from the responding application associated with the benefit inquiry request.