to HIPAA, providers of medical services submitted health care eligibility and
benefits inquiries by a variety of methods, either on paper, by phone, or
The information requirements varied depending on
· Type of insurance plan
· Specific insurer's requirements
· Type of service performed
· Where the service is performed
· Where the inquiry is initiated
· Where the inquiry is sent
provider uses the benefit inquiry transaction to ask about the benefits,
deductibles, and co-pays of the patient’s health plan and if the patient is on
file and currently is covered by the plan.
The inquiry can ask whether a specific benefit Is covered by the plan.
The transaction has the capability to inquire if a specific benefit will be
covered for the patient on a given day, but the payer is not required to answer
in this level of detail.
The response is conditional.
That is, it is not a guarantee of payment.
This transaction will be used by agents of all lines of insurance; Health,
Life, Property and Casualty to inquire about the eligibility, coverage, and
benefits accorded a prospective subscriber by a health benefit plan.
The inquiry is designed so the submitter can determine if a subscriber or
dependent is enrolled in a health benefit plan and whether projected services
for the subscriber or dependent are covered by the plan.
Healthcare eligibility request is designed so that the inquiry submitter can
· Whether an information source organization, for example, a payer,
employer, or HMO has a particular subscriber or dependent on file
· The healthcare eligibility and/or benefit information about that
subscriber and/or dependents.
transaction is used to inquire about a number of different general and specific
eligibility, coverage, and benefit attributes or conditions, for example: