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Payer Initiated Eligibility/Benefit (PIE) Transaction
(A Non-HIPAA Transaction)
DRA Companion Guide
to the
HIPAA ASC X12N Version 004010X092/A1 Implementation Guide
and
ASC X12 Version 005010X279 Technical Report Type 3
DRA Companion Guide Version 1.0
June 2010
PIE TRANSACTION DRA COMPANION GUIDE
Preface
This Companion Guide represents an electronic transaction that can be used by health
plans to transmit eligibility and benefit information to State Medicaid programs.
[This Medicaid DRA Companion Guide is provided by the Centers for Medicare & Medicaid
Services (CMS), Department of Health and Human Services, to assist State Medicaid agencies
and payers in implementing the Payer Initiated Eligibility/Benefit (PIE) Transaction. Since the
goal of this transaction is to simplify implementation for payers who must submit transactions to
multiple Medicaid agencies, Medicaid agencies should expect to receive this transaction as
described in this Guide, and may disregard any content that is not needed.
This DRA Companion Guide is written to support both American National Standards Institute
(ANSI) Accredited Standards Committee (ASC) X12N 004010X092/A1 and ASC X12
005010X279 Implementation Guides. In Section 9, Transaction Specific Information, there is an
area for the Medicaid agency to discuss its current status or plans to support these two
standards. As an alternative, the agency may remove the references to the unsupported standard
throughout the DRA Companion Guide.
Within this Guide are headers and blocks of standard language that should be used as-is by
Medicaid agencies. There are other items of text that may have to be adapted by individual
agencies; and fields that will be tagged as input items. CMS has adopted different fonts for each
of these types of text as follows:
Boilerplate text appears in black Arial font.
indicates a field that is tagged as an input item and should be replaced with information
specific to the particular Medicaid agency.
Instructions to the author appear as blue italicized text enclosed in square brackets (i.e., [text]),
and should be deleted from the final document that goes to the payers.]
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PIE TRANSACTION DRA COMPANION GUIDE
TABLE OF CONTENTS
1
INTRODUCTION...................................................................................................... 1
1.1
1.2
1.3
1.4
2
SCOPE ............................................................................................................... 1
OVERVIEW .......................................................................................................... 2
REFERENCES ...................................................................................................... 3
ADDITIONAL INFORMATION.................................................................................... 3
GETTING STARTED ............................................................................................... 3
2.1
WORKING WITH ................................................................... 3
2.2
TRADING PARTNER REGISTRATION ....................................................................... 4
3
TESTING WITH THE PAYER .................................................................................. 4
4
CONNECTIVITY WITH THE PAYER / COMMUNICATIONS .................................. 4
5
CONTACT INFORMATION ..................................................................................... 4
5.1
5.2
5.3
EDI CUSTOMER SERVICE ..................................................................................... 4
EDI TECHNICAL ASSISTANCE ............................................................................... 5
APPLICABLE WEBSITES / EMAIL.............................................................................. 5
6
CONTROL SEGMENTS / ENVELOPES ................................................................. 5
7
ACKNOWLEDGEMENTS AND/OR REPORTS ...................................................... 5
8
TRADING PARTNER AGREEMENTS .................................................................... 6
9
TRANSACTION SPECIFIC INFORMATION ........................................................... 6
Index of Tables
Table 1 – PIE Transaction Specific Information .............................................................. 7
Table 2 – Change Summary ......................................................................................... 15
Table 3 – Glossary ........................................................................................................ 16
Table 4 – Acronyms ...................................................................................................... 16
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PIE TRANSACTION DRA COMPANION GUIDE
1
INTRODUCTION
Federal law requires States to identify and obtain payment from third party entities that
are legally responsible to pay claims primary to Medicaid. To enhance States‘ ability to
identify legally liable third parties, the Deficit Reduction Act of 2005 (DRA) required
States to pass laws imposing requirements on health plans, as a condition of doing
business in the State, to provide plan eligibility information to the State.
The purpose of this Companion Guide is to assist payers in providing health plan
eligibility and coverage information to State Medicaid programs. The Centers for
Medicare & Medicaid Services developed the Payer Initiated Eligibility/Benefit (PIE)
Transaction described in this Guide which can be used to meet the DRA requirements.
The official version of the DRA Companion Guide can be found at:
www.cms.hhs.gov/ThirdPartyLiability/DRA/CompanionGuide.
The language in the
official Guide must not be altered, except to include State-specific information.
The DRA also clarified the definition of health insurer to include self-insured plans,
managed care organizations, pharmacy benefit managers, and other parties that are, by
statute, contract, or agreement, legally responsible for payment of a claim for a health
care item or service. Other parties include such entities as third party administrators,
fiscal intermediaries, and managed care contractors, who administer benefits on behalf
of the risk-bearing sponsor (e.g., an employer with a self-insured health plan). Health
insurers will be referred to as ‗payers‘ throughout this document.
1.1
SCOPE
This DRA Companion Guide is issued by to assist payers in
providing the type of information that is needed to comply with the DRA. The
Guide focuses on the exchange of data from payers to Medicaid agencies.
Agreement regarding geographic areas to be covered by the transaction and the
schedule and frequency of transaction delivery should be addressed in the
trading partner agreement.
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PIE TRANSACTION DRA COMPANION GUIDE
1.2
OVERVIEW
The Secretary adopted the following transmission formats that was developed by
American National Standards Institute (ANSI) Accredited Standards Committee
(ASC) for conducting eligibility and benefit information transactions between the
Medicaid agency, or its agent, and other payers:
ASC X12N 270/271 Health Care Eligibility/Benefit Inquiry and Response
Implementation Guide Version 004010X092/A1 (hereafter referred to as
Version 4010)
ASC X12 270/271 Health Care Eligibility/Benefit Inquiry and Response
Technical Report Type 3 Version 005010X279 (hereafter referred to as
Version 5010)
The Payer Initiated Eligibility/Benefit (PIE) Transaction will be used to provide
Medicaid agencies with a listing that identifies plan members‘ eligibility for health
coverage and their associated benefits. The PIE Transaction was developed to
deliver membership and benefit information in one single, unsolicited transaction.
The PIE Transaction uses the same identifiers as the ASC X12 271 response
transaction and therefore mirrors the format of the 271 transaction. The purpose
of this DRA Companion Guide is to provide a standardized format for the PIE
Transaction information. The information supplied on the PIE Transaction is to be
as comprehensive as possible, with beginning and end dates and including other
coverage, if available. The provided information will be used to match to the
Medicaid databases. For this purpose, a required key data element is the Social
Security Number. If the Social Security Number is not available, other key
identifiers may be used.
The DRA strengthens States‘ ability to obtain payments from health insurers by
requiring States to have laws in effect that require health insurers to make
payment as long as the claim is submitted by the Medicaid agency within 3 years
from the date on which the item or service was furnished. For this reason,
may require 3 years worth of data.
The identifiers provided by the payers on the PIE Transaction are also used to
construct HIPAA-standard eligibility inquiries as well as claims. The specific use
of these identifiers is described in Section 9 Transaction Specific Information.
The PIE Transaction DRA Companion Guide represents, in part, the guidelines
developed by the Secretary for use by Medicaid agencies and payers. These
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PIE TRANSACTION DRA COMPANION GUIDE
guidelines will provide Medicaid agencies with the information needed to bill the
appropriate payers.
1.3
REFERENCES
Deficit Reduction Act (DRA) of 2005 Section 6035
CMS Guidance on the DRA, Section 6035
http://www.cms.hhs.gov/smdl/downloads/SMD121506.pdf
http://www.cms.hhs.gov/smdl/downloads/SMD121506QandA.pdf
http://www.cms.gov/smdl/downloads/SMD10011.pdf
45 CFR Parts 160, 162, and 164 Health Insurance Reform: Security
Standards; Final Rule dated February 20, 2003
http://www.cms.hhs.gov/SecurityStandard/Downloads/securityfinalrule.pdf
ASC X12N 270/271 Health Care Eligibility/Benefit Inquiry and Response
Implementation Guide Version 004010X092/A1 (Version 4010)
ASC X12 270/271 Health Care Eligibility/Benefit Inquiry and Response
Technical Report Type 3 Version 005010X279 (Version 5010)
1.4
ADDITIONAL INFORMATION
[The Medicaid agency may add any additional information that is unique to their
environment here. If no additional information is required this section can be removed.]
2
GETTING STARTED
2.1
WORKING WITH
Please use the following contact information to coordinate the process of
establishing a working relationship with :
[Provide the full contact information for the project manager in charge of implementing
solutions to comply with the DRA. Include name, address, title, phone number, email
address, and fax number.]
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PIE TRANSACTION DRA COMPANION GUIDE
2.2
TRADING PARTNER REGISTRATION
Please use the following contact information to coordinate all trading partner
registration and trading partner agreements for :
[Provide the full contact information for the individual in your organization who is
empowered to sign trading partner agreements. Medicaid agency may wish to attach
their trading partner agreement.]
3
TESTING WITH THE PAYER
will supply payers with testing details such as access to submit
test transactions, procedures for confirming successful transmission and processing,
and procedures for submitting production transactions. Please use the following contact
information to coordinate testing with :
[Provide the full contact information for the project manager or system developer/tester in
charge of testing with payers.]
4
CONNECTIVITY WITH THE PAYER / COMMUNICATIONS
Payers should contact the individuals identified in Section 2 Getting Started to
determine the appropriate process flows, transmission and re-transmission procedures,
communications protocol and security specifications. All transmission must be secure
in accordance with 45 CFR Parts 160, 162, and 164 Health Insurance Reform: Security
Standards; Final Rule dated February 20, 2003, which can be accessed via the
following: http://www.cms.hhs.gov/SecurityStandard/Downloads/securityfinalrule.pdf.
5
CONTACT INFORMATION
Once trading partner agreements have been completed, access has been granted, and
production transmissions have begun, the following contact information should be used
for issues that arise.
5.1
EDI CUSTOMER SERVICE
[Provide contact information for the help desk support for payers regarding questions
about structure of the transmission.]
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PIE TRANSACTION DRA COMPANION GUIDE
5.2
EDI TECHNICAL ASSISTANCE
[Provide contact information for the technical support for payers regarding questions
about the connectivity and security of transmissions.]
5.3
APPLICABLE WEBSITES / EMAIL
[Provide URL and email contact information for any other information that may be
helpful to payers —e.g., on-line registration, current contact information.]
6
CONTROL SEGMENTS / ENVELOPES
The PIE Transaction conforms to ASC X12 Control Segments / Envelopes (ISA-IEA,
GS-GE, and ST-SE) for Version 4010 and Version 5010. Since files will be transmitted
infrequently, files sizes will be large and will contain more than the usual number of
records. The preferred file size and number of records will be identified in the trading
partner agreement and may change depending on the communications protocol.
Qualifiers to be used in the Sender Interchange ID Qualifier (ISA05) and Receiver
Interchange ID Qualifier (ISA07) and identifiers to be used in Interchange Sender ID
(ISA06) and Interchange Receiver ID (ISA08) will be specified in the trading partner
agreement.
7
ACKNOWLEDGEMENTS AND/OR REPORTS
A single positive ASC X12 acknowledgement will be sent indicating that the
transmission was received. For Version 4010, a functional acknowledgement (997) will
be sent; for Version 5010, an implementation acknowledgement (999) will be sent.
Negative acknowledgements will not be sent. If a positive acknowledgement is not
received, resend the file once only. If a positive acknowledgement is still not received,
contact the EDI Customer Service. Acknowledgements for
individual subscriber records within the PIE Transaction will not be sent. will not reply indicating which subscribers matched the
database.
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PIE TRANSACTION DRA COMPANION GUIDE
8
TRADING PARTNER AGREEMENTS
The sharing of information received from the payers is limited to use by the and its vendors under contract with the Medicaid agency for purposes of data
matching and coordination of benefits. The information in Section 2.2 Trading Partner
Registration will be used to coordinate trading partner agreements.
9
TRANSACTION SPECIFIC INFORMATION
requires a Subscriber Date or Dependent Date (DTP segment) in
the Subscriber Name loop (2100C) and Dependent Name loop (2100D) to identify the
range of dates covered by the eligibility information search. will
use these elements to determine whether the PIE Transaction is a full replacement or
an incremental update to previous PIE Transactions.
requires that all Eligibility or Benefit Information (EB segments)
that are appropriate to the plan be included in the Subscriber Eligibility or Benefit
Information loop (2110C); likewise the Dependent Eligibility or Benefit Information loop
(2110D) is used to provide dependent related information. Payers should provide
qualifiers that are appropriate to their coverage including, but not limited to, Eligibility
Benefit Information (EB01) and Service Type Code (EB03). To allow payers to specify
coverage, specific EB segment data elements are not supported in this DRA
Companion Guide. requires a Subscriber Eligibility/Benefit date
and Dependent Eligibility/Benefit Date (DTP segment) in the Subscriber Eligibility or
Benefit Information loop (2110C) and Dependent Eligibility or Benefit Information loop
(2110D) to specify actual start and end dates of coverage by subscriber or dependent.
Qualifiers and dates sent in the PIE Transaction will be used by to
determine whether it is appropriate to submit a claim and may be used on 270s in the
270/271 Eligibility Transaction exchange.
In the table below identifies various data components (i.e. loops,
segments, elements or qualifiers) as ―Required when available.‖ These components
may be needed for subsequent EDI transactions. There are two primary ways a
component may be used for subsequent EDI transactions:
1. The payer requires the component in order to correctly process eligibility inquiries
(270s) or claims (837s).
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PIE TRANSACTION DRA COMPANION GUIDE
2. requires the component in order to support matching to the
database, thus ensuring that allocations of payment
responsibility and subsequent claims submissions are appropriate.
When values appear in the Codes column, these values are the only values allowed. If
no values are specified for a coded element, all valid codes appearing in the 270/271
Implementation Guide are allowed.
[Here the Medicaid Agency should describe the status of their implementation of Version 4010
vs. Version 5010 unless all references to the unsupported standard have been removed.
Examples of implementation status text are:
This guidance is designed to accommodate both Version 4010 and Version 5010 standards. At
this time supports Version 4010 only. Support for Version 5010 is
scheduled to begin in Month, Year.
At this time supports both Version 4010 and 5010. Support for Version
4010 is scheduled to be discontinued Month, Year.
At this time supports Version 5010 only. ]
Table 1 represents the specific information to be included in a PIE Transaction. All
specifications must be adhered to unless both and the payer
mutually agree to any adjustments.
TABLE 1 – PIE TRANSACTION SPECIFIC INFORMATION
Page
#
4010
Page
#
5010
193
249
2100C
NM1
Subscriber Name
194
250
2100C
NM103
Subscriber Last
Name
1/35
Required
194
250
2100C
NM104
Subscriber First
Name
1/25
Required
194
250
2100C
NM105
Subscriber Middle
Name or Initial
1/25
Required when
available.
195
251
2100C
NM108
Identification Code
Qualifier
1/2
Required
June 2010
Loop
ID
Reference
Name
Codes
Length
Notes/Comments
Required
MI
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PIE TRANSACTION DRA COMPANION GUIDE
Page
#
4010
Page
#
5010
Loop
ID
Reference
Name
195
251
2100C
NM109
Identification Code
196
253
2100C
REF
Subscriber
Additional
Identification
197
254
2100C
REF01
Reference
Identification
Qualifier
Social Security
Number
198
256
2100C
REF02
Codes
Length
2/80
Notes/Comments
Required. Send
Member Identification
Number or unique
identifier required by the
payer on claims
submissions.
Required. Send a REF
segment for each
identifier available to
optimize matching to the
Medicaid agency
database. The first
occurrence of the REF
additional information
must be ―SY‖ Social
Security Number as
defined below.
2/3
SY
Required. Send the
―SY‖ Social Security
Number in the first REF
segment.
Subscriber
Supplemental
Identifier
1/30
Social Security
Number
10
Required. Send the
Social Security Number
in the first REF segment.
If the Social Security
Number is not available,
send ―999999999‖.
200
257
2100C
N3
Subscriber Address
200
257
2100C
N301
Subscriber Address
Line
1/55
Required when
available.
200
258
2100C
N302
Subscriber Address
Line
1/55
Required when the
second address line
exists.
201
259
2100C
N4
Subscriber City,
State, Zip Code
201
260
2100C
N401
Subscriber City
Name
8
Required when
available.
Required when
available.
2/30
Required when
available.
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PIE TRANSACTION DRA COMPANION GUIDE
Page
#
4010
Page
#
5010
202
260
2100C
N402
Subscriber State
Code
2/2
Required when
available.
202
260
2100C
N403
Subscriber Postal
Zone or ZIP Code
3/15
Required when
available.
210
268
2100C
DMG
Subscriber
Demographic
Information
211
269
2100C
DMG02
Subscriber Birth
Date
211
269
2100C
DMG03
Subscriber Gender
Code
216
284
2100C
DTP
Subscriber Date
216
284
2100C
DTP01
Date Time Qualifier
307
3/3
Required
217
284
2100C
DTP02
Date Time Period
Format Qualifier
RD8
2/3
Required
217
284
2100C
DPT03
Date Time Period
1/35
Required. Send the date
range that reflects the
total time period covered
by the PIE Transaction.
For instance, if the
information source is
providing data covering
the last 3 years, this date
range would show a 3
year time period ending
today even if the
subscriber was only
covered during the last
year.
219
289
2110C
EB
Eligibility or Benefit
Information
Required. Send all EB
segments and EB03
(Service Type Code)
qualifiers needed in
order to fully describe
the coverage. Do not
send inactive coverage
(EB01=6).
233
309
2110C
HSD
Health Care
Services Delivery
Required when needed
to fully define the
eligibility or benefit
represented by the
preceding EB segment.
June 2010
Loop
ID
Reference
Name
Codes
Length
Notes/Comments
Required
F,M,U
1/35
Required
1/1
Required
Required. Send the
Date Time Period that
reflects the total time
period covered by the
PIE Transaction.
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PIE TRANSACTION DRA COMPANION GUIDE
Page
#
4010
Page
#
5010
238
314
2110C
REF
Subscriber
Additional
Information
Required when
additional identifiers are
required on claims
relating to the eligibility
or benefit represented by
the preceding EB
segment.
240
317
2110C
DTP
Subscriber
Eligibility/Benefit
Date
Required. Send the
Date Time Period that
describes the eligibility
or benefit represented by
the preceding EB
segment.
240
317
2110C
DTP01
Date Time Qualifier
307
3/3
Required
241
318
2110C
DTP02
Date Time Period
Format Qualifier
RD8
2/3
Required
241
318
2110C
DTP03
Eligibility or Benefit
Date Time Period
1/35
Required. Send the
Date Time Period that
represents the actual
start and end of the
eligibility or benefit
represented by the
preceding EB segment.
If the eligibility or benefit
is open-ended (i.e., no
end date), send a date
range with an ending
date in the future, but not
farther in the future than
12/31/2099.
250
329
2120C
254
335
2120C
255
336
2120C
10
Loop
ID
Reference
Name
Codes
Length
Notes/Comments
Subscriber Benefit
Related Entity
Required when a
subscriber‘s benefitrelated entity information
(such as another
information source) is
available, e.g. a
pharmacy benefit
manager contracted by
the information source.
N3
Subscriber Benefit
Related Entity
Address
Required when
available.
N4
Subscriber Benefit
Related Entity City,
State, Zip Code
Required when
available.
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PIE TRANSACTION DRA COMPANION GUIDE
Page
#
4010
Page
#
5010
Loop
ID
Reference
Name
265
347
2000D
HL
Dependent Level
Refer to the 4010 and
5010 Implementation
Guides for usage of the
dependent loop.
271
354
2100D
NM1
Dependent Name
Required
272
355
2100D
NM103
Dependent Last
Name
1/35
Required
272
355
2100D
NM104
Dependent First
Name
1/25
Required
272
355
2100D
NM105
Dependent Middle
Name
1/25
Required when
available.
274
357
2100D
REF
Dependent
Additional
Information
275
358
2100D
REF01
Dependent
Reference
Identification
Qualifier
Social Security
Number
276
360
2100D
REF02
Length
2/3
SY
Required. Send the
―SY‖ Social Security
Number in the first REF
segment.
1/30
Social Security
Number
10
361
2100D
N3
Dependent
Address
277
361
2100D
N301
Dependent
Address Line
Notes/Comments
Required. Send a REF
segment for each
identifier available in the
information source
database to optimize
matching to the Medicaid
agency database. The
first occurrence of the
REF additional
information must be ―SY‖
Social Security Number
as defined below.
Dependent
Supplemental
Identifier
277
June 2010
Codes
Required. Send the
Social Security Number
in the first REF segment.
If the Social Security
Number is not available,
send ―999999999‖.
Required when
available.
1/55
Required when
available.
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PIE TRANSACTION DRA COMPANION GUIDE
Page
#
4010
Page
#
5010
277
362
2100D
N302
Dependent
Address Line
278
364
2100D
N4
Dependent City,
State, Zip Code
278
364
2100D
N401
Dependent City
Name
2/30
Required when
available.
279
364
2100D
N402
Dependent State
Code
2/2
Required when
available.
279
364
2100D
N403
Dependent Postal
Zone or ZIP Code
3/15
Required when
available.
287
372
2100D
DMG
Dependent
Demographic
Information
288
373
2100D
DMG02
Dependent Birth
Date
288
373
2100D
DMG03
Dependent Gender
Code
289
375
2100D
INS
Dependent
Relationship
290
376
2100D
INS01
Insured Indicator
290
376
2100D
INS02
292
377
2100D
293
388
293
294
12
Loop
ID
Reference
Name
Codes
Length
1/55
Notes/Comments
Required when the
second address line
exists.
Required when
available.
Required
F, M, U
1/35
Required
1/1
Required
Required when
available.
N
1/1
Required
Individual
Relationship Code
2/2
Required
INS17
Birth Sequence
Number
1/9
Required when
available.
2100D
DTP
Dependent Date
388
2100D
DTP01
Date Time Qualifier
307
3/3
Required
388
2100D
DTP02
Date Time Period
Format Qualifier
RD8
2/3
Required
Required. Send the
Date Time Period that
reflects the total time
period covered by the
PIE Transaction.
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PIE TRANSACTION DRA COMPANION GUIDE
Page
#
4010
Page
#
5010
294
388
2100D
DPT03
Date Time Period
295
394
2110D
EB
Eligibility or Benefit
Information
Required. Send all EB
segments and EB03
(Service Type Code)
qualifiers needed in
order to fully describe
the coverage. Do not
send inactive coverage
(EB01=6).
310
413
2110D
HSD
Health Care
Services Delivery
Required when needed
to fully define the
eligibility or benefit
represented by the
preceding EB segment.
315
417
2110D
REF
Dependent
Additional
Information
Required when
additional identifiers are
required on claims
relating to the eligibility
or benefit represented by
the preceding EB
segment.
317
421
2110D
DTP
Dependent
Eligibility / Benefit
Date
Required. Send the
Date Time Period that
describes the eligibility
or benefit represented by
the preceding EB
segment.
317
421
2110D
DTP01
Date Time Qualifier
307
3/3
Required
318
421
2110D
DTP02
Date Time Period
Format Qualifier
RD8
2/3
Required
June 2010
Loop
ID
Reference
Name
Codes
Length
1/35
Notes/Comments
Required. Send the date
range that reflects the
total time period covered
by the PIE Transaction.
For instance, if the
information source is
providing data covering
the last 3 years, this date
range would show a 3
year time period ending
today even if the
dependent was only
covered during the last
year.
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PIE TRANSACTION DRA COMPANION GUIDE
Page
#
4010
Page
#
5010
318
421
2110D
327
433
2120D
331
438
2120D
332
439
2120D
14
Loop
ID
Reference
DTP03
Name
Eligibility or Benefit
Date Time Period
Codes
Length
1/35
Notes/Comments
Required. Send the Date
Time Period that
represents the actual
start and end of the
eligibility or benefit
represented by the
preceding EB segment.
If the eligibility or benefit
is open-ended (i.e., no
end date), send a date
range with an ending
date in the future, but not
farther in the future than
12/31/2099.
Dependent Benefit
Related Entity
Required when a
dependent‘s benefitrelated entity information
(such as another
information source) is
available, e.g. a
pharmacy benefit
manager contracted by
the information source.
N3
Dependent Benefit
Related Entity
Address
Required when
available.
N4
Dependent Benefit
Related Entity City,
State, Zip Code
Required when
available.
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PIE TRANSACTION DRA COMPANION GUIDE
Appendix A Implementation Checklist
[This section may be deleted, or the Medicaid agency may add instructions here. This may
include trading partner agreement set-up, steps to establish connectivity, and testing.]
Appendix B Business Scenarios
The PIE Transaction will be submitted to on a predetermined
schedule and frequency using the transmission mechanism and schedule and including
subscribers (and dependents) residing in the appropriate geographic areas as agreed
upon in the trading partner agreement. The Health Care Eligibility Benefit Inquiry and
Response (270/271) may be used to clarify or update coverage information as part of
the Medicaid coordination of benefits and cost recovery processes. For more
information about the business context and the benefits to payers and Medicaid
agencies, visit the following:
www.cms.hhs.gov/ThirdPartyLiability/DRA/CompanionGuideBusinessScenarios
Appendix C Change Summary
[The Medicaid agency will indicate key changes to the document. A sample matrix is provided
and may be modified to effectively communicate changes to the payers.]
TABLE 2 – CHANGE SUMMARY
Version
Date
Organization/Point of Contact
Description of Changes
1.0
Office
Initial Version
1.1
Office
Updated Contact Information.
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Appendix D Glossary and Acronyms
TABLE 3 – GLOSSARY
Term
Definition
Information
Receiver
In the case of the PIE Transaction, the information receiver is .
Information Source
In the case of the PIE Transaction, the information source is also referred to as the
payer.
Payer
In this DRA Companion Guide, payer refers to the ―health insurer‖. Section 6035
clarified the definition of health insurer to include self-insured plans, managed care
organizations, pharmacy benefit managers and other parties that are, by statute,
contract, or agreement, legally responsible for payment of a claim for a health care
item or service. Other parties include such entities as third party administrators,
fiscal intermediaries, and managed care contractors, who administer benefits on
behalf of the risk-bearing sponsor (e.g., an employer with a self-insured health
plan).
TABLE 4 – ACRONYMS
Acronym
Definition
2100C
Subscriber loop
2110C
Subscriber Eligibility or Benefit Information loop
2120C
Subscriber Benefit Related Entity loop
2100D
Dependent loop
2110D
Dependent Eligibility or Benefit Information loop
2120D
Dependent Benefit Related Entity loop
270
A HIPAA-compliant transaction used to request information about eligibility for
benefits.
271
A HIPAA-compliant transaction used to return information about a subscriber‘s
eligibility for benefits.
997
A functional acknowledgement. An ASC X12N standard transaction used either to
acknowledge receipt of a 270 transaction or to reject a transaction based on failure
in the content of the request.
999
An implementation acknowledgement. An ASC X12 standard transaction used to
acknowledge receipt of a batch 270.
ASC X12
ASC X12 is a standard for EDI that is sponsored by the American National
Standards Institute Accredited Standards Committee. It is a selected standard for
HIPAA-compliant transactions.
CFR
Code of Federal Regulations
CMS
Centers for Medicare & Medicaid Services
DRA
Deficit Reduction Act
DTP
Date or Time or Period—this segment is used to provide a date or date range in an
ASC X12 transaction. This segment can be found in multiple places in the
transaction.
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PIE TRANSACTION DRA COMPANION GUIDE
Acronym
Definition
EB
Eligibility or Benefit Information—This segment supplies eligibility and benefit
information. It can be used in both the subscriber and dependent loops.
EB01
Eligibility or Benefit Information Code identifies eligibility or benefit information
provided in the EB segment.
EB03
Service Type Code classifies the type of service described in the EB segment.
EDI
Electronic Data Interchange is a subset of Electronic Commerce. It is a set of
standardized electronic business documents, which are exchanged in agreed-upon
formats.
HIPAA
Health Insurance Portability and Accountability Act of 1996 (Title II). Title II of
HIPAA, known as the Administrative Simplification provisions, requires the
establishment of national standards for electronic health care transactions and
national identifiers for covered entity providers, health insurance plans, and
clearing houses.
The Administrative Simplification provisions also address the security and privacy
of health data. The standards are meant to improve the efficiency and effectiveness
of the nation's health care system by encouraging the widespread use of EDI in the
U.S. health care system.
ISA
Interchange Control Header
ISA04
Security Information (ISA)
ISA05
Interchange ID Qualifier (ISA) designates the system/method of code structure
used to designate the Sender ID element being qualified.
ISA06
Interchange Sender ID (ISA)
ISA07
Interchange ID Qualifier (ISA) designates the system/method of code structure
used to designate the Receiver ID element being qualified.
ISA08
Interchange Receiver ID (ISA)
PIE
Payer Initiated Eligibility/Benefit—This is the transaction developed by CMS that
can be used by the Medicaid agencies to obtain eligibility and benefit information
from payers in a single unsolicited transaction.
X12
X12 is a standard for EDI that is sponsored by the American National Standards
Institute Accredited Standards Committee. The proper designation is ASC X12. It
is a selected standard for HIPAA-compliant transactions.
X12N
X12 is a standard for EDI that is sponsored by the American National Standards
Institute Accredited Standards Committee. It is a selected standard for HIPAAcompliant transactions. The ―N‖ designates the Insurance subcommittee. The ―N‖
reference has been dropped in more recent standards.
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| File Type | application/pdf |
| File Modified | 2012-03-14 |
| File Created | 2010-10-20 |