HIPAA 5010: Changes in Individual Transaction

270- Eligibility Request

· Added search option wit Member ID, last name and date of birth.

· Added support for additional 38 Patient Service Type codes.

· Added benefit search based on Diagnosis Codes.

271- Eligibility Response

· Changes are made to clarify that when a patient has active benefit coverage, the health plan must report: Beginning effective date, Plan Name and the benefit effective date if different from overall coverage.

· New Health Plan requirements are added to the 271 Eligibility response.

· New requirements are added to specify nine category of benefits to be reported if available the patient.

· When reporting on co-insurance, co-payment and deductible, it’s now explicitly required that patient portion of payment is to be reflected in either monetary or percentage amount.

276/277- Claim Status Request and Response

· Sensitive Private Health information is removed for status check purpose.

· REF segment can now be used to identify prescription number for pharmacy information.

· Specific tracing number can be recorded (modified TRM segment).

· New requirements allow Payer to report more status code (STC) and greater details about the claim status.

287- Health Care Service Certification

· Structural changes are made which enables to group information about patient events such as diagnosis, category of service hierarchically.

· Procedures are moved to from Healthcare information code segment (HI) to professional (SV1), institutional (SV2) and dental (SV3).

· The 278 TR3 also clarified the use of the patient condition segment, by adding separate implementation segments and rules.

· Reject reason code data elements was changed, now to be a repeating data element to allow multiple reject codes to be reported.

837- Healthcare Claims (I, P and D)

· Subscriber information is not reported if Patient information uniquely identifies the patient.

· Clearly defined as to how NPI subparts are to be reported structurally.

· A separate element is added to report tax number.

· ICD-10 is supported.

835- Claim Payment/Remittance

· A remittance delivery method segment is added.

· A new Healthcare Medicare Policy segment is added.

· Segment is added to supply the Payer URL.

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