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Healthcare eligibility request message processing

Updated on April 23, 2021

The Foundation provides preconfigured rules to process real-time 270 Eligibility Request messages. The X12 parsing rules are configured per the X12 270/271 Implementation Guide of the Standard and support batch as well as real-time message processing.

Pega Foundation for Healthcare

The sample scenarios included in the Foundation reflect a real-time processing situation with an immediate response generated after processing the message. To reflect that real-time situation, the messages are limited to one benefit request per member (subscriber or patient).

The key functionality includes:

  • X12 270 Message Parsing — Per the 270/271 Implementation Guide
  • Eligibility Request Work Object Creation — For every benefit request submitted in the transaction
  • Validation of Information Source Level
    • Check Limit Validation — Sample business validation rule evaluates for the number of benefit requests in a single transaction. The validation fails if the number exceeds a pre-defined threshold for real-time processing (Foundation parameter is set at 25). If validation fails, further processing of the message is skipped, and an appropriate AAA Request Validation segment is included in this loop in the outbound 271 message.
      • AAA01 = Y
      • -AAA03 = 04
      • AAA04 = C
  • Validation of Information Receiver Level
    • Check for Provider on File — The sample business validation rule that searches for the provider record based on the Information Receiver record is not found in the sample database. If validation fails, further processing of the message is skipped, and an appropriate AAA Request Validation segment is included in this loop in the outbound 271 message.
    • AAA01 = Y
    • AAA03 = 51
    • AAA04 = C
  • Validation of Subscriber Level
    • Check for Subscriber on File — Sample business validation rule that searches for the subscriber record based on the Subscriber ID submitted on the 270. The validation fails if a matching subscriber record is not found in the sample database. If validation fails, further processing of the message is skipped, and an appropriate AAA Request Validation segment is included in this loop in the outbound 271 message.
  • AAA01 = Y
  • AAA03 = 75
  • AAA04 = C
  • Eligibility Benefit Request Processing
    • Check for Active Policy — If validation fails, an appropriate EB segment is returned in the 271 message.
      • EB*6**30~
      • EB01 = 6 (Inactive)
      • EB03 = 30 (Health Benefit Plan Coverage)
    • Check Eligibility On Service Date — The validation fails if the requested service date is outside the effective period on the active policy. If validation fails, an appropriate EB segment is returned in the 271 message.
      • EB*I**30~
      • EB01 = I (Non Covered)
      • EB03 = 30 (Health Benefit Plan Coverage)
    • Process Generic Eligibility Request — The following 2110C/D EB03 values are returned if they are a covered benefit category at a plan level.
      • 1 - Medical Care
      • 33 - Chiropractic
      • 35 - Dental Care
      • 47 - Hospital
      • 86 - Emergency Services
      • 88 - Pharmacy
      • 98 - Professional (Physician) Visit – Office
      • AL - Vision (Optometry)
      • MH - Mental Health
      • UC - Urgent Care
    • If a specific EQ segment is not submitted on the 270, a minimum eligibility information response is returned in the corresponding EB segment on the 271 response message.
    • X12 271 Message Generation — per the 270/271 Implementation Guide.

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