IHCLME Health care claim or encounter request and response

D11 Healthcare (SWG)

This message is to support interactive submittal and response of health care claims or encounters for the point of sale environment. It will be used in health care information scenarios when immediate response is appropriate.

Header

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

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

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

  4. To specify contact communication numbers and names.

  5. To provide billable information for a claim or encounter.

  6. To provide specific claim information for services performed while admitted to an institution.

  7. To provide adjudication information for all services in a health care claim.

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

  9. Segment group 1
    Repeat 3
    1. To provide payer, insured, and payment information when benefits are being coordinated between third party benefit carriers.

    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.

  10. Segment group 2
    Repeat 99
    1. To provide detail information about the service.

    2. To provide specific tooth and oral cavity information.

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