1. SCOPE
   1. Functional definition
   2. Field of application
   3. Principles
2. REFERENCES
3. TERMS AND DEFINITIONS
   1. Standard terms and definitions
4. MESSAGE DEFINITION
   1. Segment clarification
   2. Segment index (alphabetical sequence by tag)
   3. Message structure
      1. Segment table

This specification provides the definition of the Health care claim or encounter request and response - interactive message (IHCLME) to be used in Electronic Data Interchange (EDI) between trading partners involved in administration, commerce and transport.

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.

The Health care claim or encounter request and response - interactive message may be used for both national and international applications. It is based on universal practice related to administration, commerce and transport, and is not dependent on the type of business or industry.

This message establishes the data contents of the IHCLME. This can be used to create interactive communications between health care providers (e.g., physicians, hospitals, other medical facilities, dentists, etc.), health care information processors, health care payers, and/or their agents. The information includes, but is not limited to, billing information (for full or partial adjudication), encounter reporting, additional service information (denial reasons, errors, pending data, etc.), and coordination of benefits.

IHCLME may be used for the following functions within the claim or encounter scenario for health care:

(1) To request and respond to a request for processing a claim or encounter episode. (2) To request and respond to a request to modify or cancel a previously submitted claim or encounter. (3) To request and respond to a pre-determination of benefits as it relates to a covered life. (4) To request and respond to a need for additional information as it relates to a claim or encounter episode.

An example of health care processors or their agents includes:

• Insurance Companies
• Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPOs)
• Health Care Purchasers (e.g., employers)
• Professional Review Organizations (PROs)
• Social Worker Organizations
• Health Care Providers (e.g., physicians, hospitals, laboratories)
• Third Party Administrators (TPAs)
• Health Care Vendors (e.g., practice management vendors, billing services)
• Service Bureaus (value added networks or value added banks)
• Government agencies such as Medicare, Medicaid and Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).

See UNTDID, Part 4, Chapter 2.3 UN/ECE UNSM - General Introduction, Section 1.

See UNTDID, Part 4, Chapter 2.3 UN/ECE UNSM - General Introduction, Section 2.

This section should be read in conjunction with the segment table which indicates mandatory, conditional and repeating requirements.

0010 UIH, Interactive message header

A service segment starting and uniquely identifying a message. The message type code for the Health care claim or encounter request and response - interactive message is IHCLME.

Note: Health care claim or encounter request and response - interactive messages conforming to this document must contain the following data in segment UIH, composite S306:

0020 MSD, Message action details

To specify the message processing requirements, response type, and to provide a tracking mechanism. The reference number in this segment will provide for a different tracking number than what is generated in the message envelope, for application level tracking.

0030 PRT, Party information

To provide specific identification numbers and demographic information regarding the identity of the participating parties. Date of birth, eligibility date, and date of death may be specified as well as relationship between the patient and the insured, sex, employment category, marital status, student status, and a yes or no indication of whether the patient is pregnant.

0040 NAA, Name and address

To specify a party identity, and, when necessary, the name and/or the address in either a structured or unstructured format. For use in health care, it is recommended to use only the identification, but if the name or address are needed, to use only the structured method of submittal.

0050 CON, Contact information

To provide electronic message routing information for additional recipients of this message. The reference number will provide a unique reference number to be used by the contact entity when referring to this message.

0060 BLI, Billable information

To provide summarized information about all services covered under one health care claim or encounter. This segment allows detail relating to monetary amounts for the total amount being charged for the claim, total amount that the patient has paid, and the total amount paid by other benefit carriers. Multiple diagnoses that apply to the entire claim, and multiple dates may be conveyed. The plan sponsor can receive the reference of any pre-authorization information associated with the claim and through a series of yes and no indications will know whether the provider accepts the insurance payment as payment in full, and whether the patient has signed documents releasing the medical information to the insurance carrier and authorizing the payment directly to the provider. The presence, nature, date, and state or province of a cause related to this claim, such as an accident, may also be indicated.

0070 ITC, Institutional claim

To provide specific claim information only needed when processing claims for services performed while admitted to a health care institution. When the claim is generated from a health care institution, additional information such as the type (e.g. first, intermediate, last) and frequency of invoicing during an extended admission, the number of days covered and non covered by insurance, the type (e.g. emergency, scheduled) and source of admission, the discharge type (e.g. ambulatory, transfer, dead), and information about other products and services related to the institutional admission may be needed.

0080 ADI, Health care claim adjudication information

To provide adjudication information for all services, supplies or products in the health care claim. The internal control number assigned by the payer, the specific service trace or sequence number designated for this service in the original claim, the payment or draft control number, the health care service being paid, the health case service originally billed, the health care service institutional "revenue" code, the notification of the adjudication action taken by the payer, the total amount paid, other informational amounts (e.g negotiated discount), the number of services adjudicated, the number of services originally billed, the importance given to the diagnosis related group in calculating the payment, the financial adjustments (e.g. deductible, agreed fee limit) made in the adjudication, identification of health care policy limitations, the insurance product group (e.g. indemnity, managed care, federal program), the anticipated date of payment, the diagnosis category from a diagnosis related grouping program, and the percentage known as "discharge fraction" may all be sent in this segment.

0090 FRM, Follow-up action

To identify specific corrective actions that should occur before the adjudication process can complete. The identity number in this segment must be one of the identity number given in an ADI segment. The follow-up actions may be for the entire claim or may be service specific.

0100 Segment Group 1: OTI-NAA

A group of segments to identify all parties by code and name that may provide insurance coverage for the patient being treated.

0110 OTI, Other insurance

To provide payer, insured and payment information when benefits are being coordinated between third party benefit carriers. A major source of concern in health care is being able to coordinate benefits between multiple insurance carriers. This segment will be used to reference other payers that may need to be kept abreast of the health care transaction and what monetary amounts are being paid by the respective carrier. Even though three different carriers may be identified, there is a yes or no indicator that will allow the indication of additional carriers beyond what is being sent.

0120 NAA, Name and address

To specify identification numbers, name and address information relating to the other insurance parties. If available, the identification number of the insurance carrier should be used. When the identification number is not available, or the insurance carrier operates out of multiple offices, the name and/or address should be used.

0130 Segment Group 2: PSI-DNT

To identify the specific service information for the claim or encounter.

0140 PSI, Service information

To provide detail information about the service, product, or procedure. This segment allows the payer of a health care transaction to indicate line item detail about all services performed. All charges can be broken down, several of the diagnosis codes from the claim can be references with an index identifier, and any supporting evidence and out of band additional information needed for the claim can be referenced.

0150 DNT, Dental information

To provide specific a complete description of each tooth in relation to the service. Only in a dental claim, would the payer need to know specific tooth and additional information on the surface, gum depth or status.

0160 UIT, Interactive message trailer

A service segment ending a message, giving the total number of segments in the message (including the UIH & UIT) and the control reference number of the message.