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The HITSP Patient Health Plan Eligibility Verification Transaction is intended to provide an individuals coverage status from a health plan, along with details regarding patient liability for deductible, co-pay and co-insurance amounts. It can be used for a defined base set of general benefits or services or for specific services based on service types, procedure codes, or diagnoses.
To support Patient Health Plan Eligibility Verification, HITSP is using the Accredited Standards Committee (ASC) X12 270 and 271 transaction standards version 4010, using the Insurance Subcommittee X12N Implementation Guides reference number 004010X92 plus an Addenda reference number 004010X92A1. This X12N Implementation Guide is also being constrained by HITSP via the CAQH CORE Phase I and Phase II Operating Rules for the ASC X12 270/271 Eligibility and Benefits Inquiry and Response. The CAQH CORE Phase I and Phase II Operating Rules bring additional and other requirements permitted within the X12 standards for the exchange of the HIPAA-adopted X12N 270/271 Eligibility and Benefit Inquiry and Response Transactions between a healthcare provider (information requester) and a health plan (information source). They are focused on providing operating rules for more useful and consistent conduct of the 270/271 transactions between any information requester (such as a private physician office, a clinic or an acute care in-patient facility) and any information source (such as a health plan, an insurance company or a third-party administrator).
This Transaction may not define all functions, constructs and standards necessary to implement a conforming system in a real world environment. In particular, an implementer must provide the technical infrastructure and security framework necessary to support operations in accordance with law, regulation, best practices and business agreements.
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2009 ANSI. This material may be copied without permission from ANSI only if and to the extent that the text is not altered in any fashion and ANSIs copyright is clearly noted.
This section provides a list of key reference documents and background material.
A list of key reference documents and background material is provided in the table below. These documents can be retrieved from www.hitsp.org Web Site.
Table 1-1 Reference Documents
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Reference Document |
Document Description |
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Lists and defines the acronyms used in this document |
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Provides definitions for relevant terms used by HITSP documents |
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TN900 is a reference document that provides the overall context for use of the HITSP Security and Privacy constructs |
This section describes the conformance criteria, which are objective statements of requirements that can be used to determine if a specific behavior, function, interface or code set has been implemented correctly.
Claims of conformance may only be made for the overall HITSP Interoperability Specification or Capability with which this construct is associated.
A HITSP Interoperability Specification must be implemented in its entirety for an implementation to claim conformance to the specification. HITSP may define the permissibility for interface scoping, subsetting or implementation options by which the specification may be implemented in a limited manner. Such scoping, subsetting and options may extend to associated constructs, such as this construct. This construct must implement all requirements within the selected scope, subset or options as defined in the associated Interoperability Specification to claim conformance.
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