IHCEBI Interactive health insurance eligibility and benefits inquiry and

TBG10 Healthcare

The IHCEBI message is sent from institutional or individual health care providers or those providing related administrative services to a funding institution to obtain health insurance information from a patient's health plan prior to or at the time of admission or treatment.

This inquiry message will allow a health care provider to give their patient an estimate of cost for certain treatments, or assess their own financial risk associated with certain treatments, and provide the patient with informed financial choices regarding their health care options.

Each inquiry can provide information to the health plan about a service being considered, (e.g., actual or expected service dates, actual or expected duration of hospital stay, and planned services). An inquiry can also contain information about the treating and referring practitioner, if they are not the health care party making the inquiry.

The response message will provide information regarding what benefits are available to the patient based on their health plan contract and the information provided with the inquiry. This can include financial information, such as, co-pay amounts, deductible amounts, limitations, and exclusions.

Each response can also provide information regarding administrative issues concerning a covered benefit, such as, indicate who is the primary provider for a service, contact information for the health plan and patient, and policy rules, such as, certain screening exams can only be done once every two years.

Header

Position
Segment
Name
Max use
  1. To specify the message and business function and to provide a tracking mechanism.

  2. Segment group 1
    Repeat 9
    1. To provide specific identification number and demographic information regarding the identity of the participating parties.

    2. To specify the name/address and their related function, either by E082 only and/or unstructured by E058 or structured by E080 through 3207.

    3. To specify contact communication numbers and names.

    4. To identify a follow-up action that should occur.

  3. Segment group 2
    Repeat 1
    1. To specify dates and times, related text and time references.

    2. To specify a type of insurance, if it is required, and the coverage, limit, and deductible amounts.

    3. To identify a follow-up action that should occur.

    4. Segment group 3
      Repeat 999
      1. A segment to identify and provide information about benefit and coverage.

      2. A segment to provide specific information about covered benefit services, which is used to report a diagnosis to show necessity, the service or procedure being requested or provided, and service delivery instructions.

      3. To specify dates and times, related text and time references.

      4. To provide specific identification number and demographic information regarding the identity of the participating parties.

      5. To identify a follow-up action that should occur.

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