Medicare 271 Transaction Example Using The HETS Application EB 270/271 5010271Response Current
User Manual: EB 270/271
Open the PDF directly: View PDF 
.
Page Count: 10
| Download | |
| Open PDF In Browser | View PDF |
Medicare 5010A1 271 Transaction Example using the HETS Application Not all of the information presented in this example will be on every Medicare 271 response. This example is for illustrative purposes only and shows the various eligibility information that a 271 response may contain, including Part A, Part B, SNF, Hospital, Preventive, Smoking Cessation, Blood Deductible, Hospice, MSP, Home Health, Medicare Advantage, Part D, Inactive Periods, Rehabilitation, and Occupational, Physical, & Speech Therapies. Note: The information in Table 1 is a representative example from the upcoming HETS R2016Q300 release. Table 1: Medicare 5010A1 271 Transaction Example 271 Segment ISA*00* *00* HETS Returned Values *ZZ*CMS *ZZ*SUBMITTERID *160130*0758*^*00501*111111111*0*P*|~ GS*HB*CMS*SUBMITTERID*20160130*07580000*1*X*005010X279A1~ ST*271*0001*005010X279A1~ BHT*0022*11*TRANSA*20160130*07582355~ HL*1**20*1~ NM1*PR*2*CMS*****PI*CMS~ HL*2*1*21*1~ NM1*1P*2*IRNAME*****XX*1234567893~ HL*3*2*22*0~ TRN*2*TRACKNUM*ABCDEFGHIJ~ NM1*IL*1*LNAME*FNAME*M***MI*HICN~ N3*ADDRESS LINE1*ADDRESS LINE2~ N4*CITY*ST*ZIPCODE~ DMG*D8*19400401*F~ DTP*307*RD8*20150927-20160430~ The following segments illustrate an Inactive (Alien, Deported, or Incarcerated) period. EB*6**30~ DTP*307*RD8*20151101-20151103~ The following segment illustrates HETS supported Service Type Codes (STC) not covered by Medicare EB*I**41^54~ The following segment illustrates active or inactive Part D Coverage Date of Last Revision: 06/10/2016 ISA06 = “CMS” plus spaces (will be 15 bytes) ISA08 = Submitter ID plus spaces (will be 15 bytes) GS02 = “CMS” GS03 = Submitter ID N/A N/A N/A NM101 = “PR” NM102 = “2” NM103 = “CMS” NM108 = “PI” NM109 = “CMS” N/A NM101 = “1P”, “FA”, or “80” N/A N/A NM109 = HICN N/A N/A N/A DTP03 = Date(s) of Service from the 270 inquiry N/A N/A DTP03 = Part A and Part B Entitlement Inactive Date(s) N/A N/A N/A Page 1 271 Segment HETS Returned Values EB*1**88~ The following segments illustrate Part A Entitlement/Coverage EB*1**30^10^42^45^48^49^69^76^83^A5^A7^AG^BT^BU^BV*MA~ EB01= Status of Coverage "1" or "6" N/A EB03= "30" and applicable HETS supported Service Type Codes EB04= "MA" DTP03 = Entitlement and Termination Dates (where applicable) N/A EB07 = Part A Base Deductible 2016 DTP03= Calendar Year EB07 = Part A Base Deductible 2015 DTP03= Calendar Year EB07 = Part A Base Deductible as Remaining 2016 DTP03= Calendar Year EB07 = Part A Base Deductible as Remaining 2015 DTP03= Calendar Year EB07 = Part A Spell Deductible Remaining 2016 DTP03 = Part A Spell DOEBA-DOLBA for Deductible Remaining N/A EB07 = Part A Base Deductible is not applicable 2016 DTP03 = Calendar Year EB07 = Part A Base Deductible is not applicable 2015 DTP03 = Calendar Year To receive Hospital Data the 270 request MUST contain STC= 47, 48, 49, A5, A7 and/or AG EB07 = Part A Co-Payment per day (Fully Cov Days) 2016 HSD06 = "0" (Illustrates days exceeding 0) HSD06 = "60" (Illustrates through day 60) HSD06 = "1" (per Part A Spell) DTP03 = Calendar Year EB07 = Part A Spell Daily Co-Payment Amount 2016 HSD06 = "60" (Illustrates days exceeding 60) HSD06 = "90" (Illustrates through day 90) HSD06 = "1" (per Part A Spell) DTP03 = Calendar Year EB07 = Part A Co-Payment per day (Fully Cov Days) 2015 HSD06 = "0" (Illustrates days exceeding 0) HSD06 = "60" (Illustrates through day 60) HSD06 = "1" (per Part A Spell) DTP*291*D8*20050401~ The following segments illustrate Part A Deductible Financial Data EB*C**30*MA**26*1288~ DTP*291*RD8*20160101-20161231~ EB*C**30*MA**26*1260~ DTP*291*RD8*20150101-20151231~ EB*C**30*MA**29*1288~ DTP*291*RD8*20160101-20161231~ EB*C**30*MA**29*1260~ DTP*291*RD8*20150101-20151231~ EB*C**30*MA**29*0~ DTP*291*RD8*20160114-20160120~ The following segments illustrate Part A “Free” Services EB*C**42^45*MA**26*0~ DTP*292*RD8*20160101-20161231~ EB*C**42^45*MA**26*0~ DTP*292*RD8*20150101-20151231~ The following segments illustrate Part A Hospital Days Base EB*B**30*MA**7*0~ HSD***DA**30*0~ HSD***DA**31*60~ HSD*****26*1~ DTP*435*RD8*20160101-20161231~ EB*B**30*MA**7*322~ HSD***DA**30*60~ HSD***DA**31*90~ HSD*****26*1~ DTP*435*RD8*20160101-20161231~ EB*B**30*MA**7*0~ HSD***DA**30*0~ HSD***DA**31*60~ HSD*****26*1~ Date of Last Revision: 06/10/2016 Page 2 271 Segment HETS Returned Values DTP*435*RD8*20150101-20151231~ EB*B**30*MA**7*315~ HSD***DA**30*60~ HSD***DA**31*90~ HSD*****26*1~ DTP*435*RD8*20150101-20151231~ The following segments illustrate Part A Hospital Days Remaining when no spell applies DTP03 = Calendar Year EB07 = Part A Spell Daily Co-Payment Amount 2015 HSD06 = "60" (Illustrates days exceeding 60) HSD06 = "90" (Illustrates through day 90) HSD06 = "1" (per Part A Spell) DTP03 = Calendar Year To receive Hospital Data the 270 request MUST contain STC= 47, 48, 49, A5, A7 and/or AG EB07 = Part A Co-Payment per day (Fully Cov Days) 2016 HSD06 = "60" for Part A Spell Fully-Covered Days Remaining HSD06 = "1" (per Part A Spell) DTP03 = Calendar Year EB07 = Part A Spell Daily Co-Payment Amount 2016 HSD06 = "30" for Part A Spell Co-Payment Days Remaining HSD06 = "1" (per Part A Spell) DTP03 = Calendar Year EB07 = Part A Co-Payment per day (Fully Cov Days) 2015 HSD06 = "60" for Part A Spell Fully-Covered Days Remaining HSD06 = "1" (per Part A Spell) DTP03 = Calendar Year EB07 = Part A Spell Daily Co-Payment Amount 2015 HSD06 = "30" for Part A Spell Co-Payment Days Remaining HSD06 = "1" (per Part A Spell) DTP03 = Calendar Year To receive Spell Data the 270 request MUST contain STC= 47, 48, 49, A5, A7 and/or AG and spell must be present within 60 days of search request date. EB07 = Part A Co-Payment per day (Fully Cov Days) 2016 HSD06 = Part A Spell Fully-Covered Days Remaining HSD06 = "1" (per Part A Spell) DTP03 = Part A Spell DOEBA-DOLBA EB07 = Part A Spell Daily Co-Payment Amount 2016 HSD06 = Part A Spell Co-Payment Days Remaining HSD06 = "1" (per Part A Spell) DTP03 = Part A Spell DOEBA-DOLBA To receive Skilled Nursing Facility Data the 270 request MUST contain STC= AG EB*B**30*MA**7*0~ HSD***DA**29*60~ HSD*****26*1~ DTP*435*RD8*20160101-20161231~ EB*B**30*MA**7*322~ HSD***DA**29*30~ HSD*****26*1~ DTP*435*RD8*20160101-20161231~ EB*B**30*MA**7*0~ HSD***DA**29*60~ HSD*****26*1~ DTP*435*RD8*20150101-20151231~ EB*B**30*MA**7*315~ HSD***DA**29*30~ HSD*****26*1~ DTP*435*RD8*20150101-20151231~ The following segments illustrate Hospital Days Remaining in a Part A Spell EB*B**30*MA**7*0~ HSD***DA**29*56~ HSD*****26*1~ DTP*435*RD8*20160114-20160120~ EB*B**30*MA**7*322~ HSD***DA**29*30~ HSD*****26*1~ DTP*435*RD8*20160114-20160120~ The following segments illustrate Part A SNF Days Base Date of Last Revision: 06/10/2016 Page 3 271 Segment HETS Returned Values EB*B**AG*MA**7*0~ HSD***DA**30*0~ HSD***DA**31*20~ HSD*****26*1~ DTP*435*RD8*20160101-20161231~ EB*B**AG*MA**7*161~ HSD***DA**30*20~ HSD***DA**31*100~ HSD*****26*1~ DTP*435*RD8*20160101-20161231~ EB*B**AG*MA**7*0~ HSD***DA**30*0~ HSD***DA**31*20~ HSD*****26*1~ DTP*435*RD8*20150101-20151231~ EB*B**AG*MA**7*157.5~ HSD***DA**30*20~ HSD***DA**31*100~ HSD*****26*1~ DTP*435*RD8*20150101-20151231~ The following segments illustrate Part A SNF Days Remaining when no spell applies EB07 = Part A SNF Co-Payment per day (Fully Cov Days) 2016 HSD06 = "0" (Illustrates days exceeding 0) HSD06 = "20" (Illustrates through day 20) HSD06 = "1" (per SNF Spell) DTP03 = Calendar Year EB07 = Part A Spell SNF Daily Co-Payment Amount 2016 HSD06 = "20" (Illustrates days exceeding 20) HSD06 = "100" (Illustrates through day 100) HSD06 = "1" (per SNF Spell) DTP03 = Calendar Year EB07 = Part A SNF Co-Payment per day (Fully Cov Days) 2015 HSD06 = "0" (Illustrates days exceeding 0) HSD06 = "20" (Illustrates through day 20) HSD06 = "1" (per SNF Spell) DTP03 = Calendar Year EB07 = Part A Spell SNF Daily Co-Payment Amount 2015 HSD06 = "20" (Illustrates days exceeding 20) HSD06 = "100" (Illustrates through day 100) HSD06 = "1" (per SNF Spell) DTP03 = Calendar Year To receive Skilled Nursing Facility Data the 270 request MUST contain STC= AG EB07 = Part A SNF Co-Payment per day (Fully Cov Days) 2016 HSD06 = "20" for Part A Spell SNF Fully-Covered Days Remaining HSD06 = "1" (per SNF Spell) DTP03 = Calendar Year EB07 = Part A Spell SNF Daily Co-Payment Amount 2016 HSD06 = "80" for Part A Spell SNF Co-Payment Days Remaining HSD06 = "1" (per SNF Spell) DTP03 = Calendar Year EB07 = Part A SNF Co-Payment per day (Fully Cov Days) 2015 HSD06 = "20" for Part A Spell SNF Fully-Covered Days Remaining HSD06 = "1" (per SNF Spell) DTP03 = Calendar Year EB07 = Part A Spell SNF Daily Co-Payment Amount 2015 HSD06 = "80" for Part A Spell SNF Co-Payment Days Remaining HSD06 = "1" (per SNF Spell) EB*B**AG*MA**7*0~ HSD***DA**29*20~ HSD*****26*1~ DTP*435*RD8*20160101-20161231~ EB*B**AG*MA**7*161~ HSD***DA**29*80~ HSD*****26*1~ DTP*435*RD8*20160101-20161231~ EB*B**AG*MA**7*0~ HSD***DA**29*20~ HSD*****26*1~ DTP*435*RD8*20150101-20151231~ EB*B**AG*MA**7*157.5~ HSD***DA**29*80~ HSD*****26*1~ Date of Last Revision: 06/10/2016 Page 4 271 Segment HETS Returned Values DTP*435*RD8*20150101-20151231~ The following segments illustrate Part A SNF Spell Days Remaining in a Part A Spell DTP03 = Calendar Year To receive Spell SNF Data the 270 request MUST contain STC= AG and spell must be present within 60 days of search request date. EB07 = Part A SNF Co-Payment per day (Fully Cov Days) 2016 HSD06 = Part A Spell SNF Fully-Covered Days Remaining HSD06 = Per SNF Spell DTP03 = Part A Spell DOEBA-DOLBA EB07 = Part A Spell SNF Daily Co-Payment Amount 2016 HSD06 = Part A Spell SNF Co-Payment Days Remaining HSD06 = Per SNF Spell DTP03 = Part A Spell DOEBA-DOLBA To receive Lifetime Reserve Data the 270 request MUST contain STC= 47, 48, 49, A5, A7 and/or AG. EB10 = Part A Lifetime Reserve Base Days EB10 = Part A Lifetime Reserve Remaining Days EB07 = Part A Co-Payment amount per day 2016 DTP03 = Calendar Year EB07 = Part A Co-Payment amount per day 2015 DTP03 = Calendar Year To receive Lifetime Psychiatric Limitation Data the 270 request MUST contain STC= A7. Submitters are only permitted to request STC A7 on behalf of Psychiatric/Mental Health professionals and institutions. Compliance will be monitored by CMS. EB10 = Part A Lifetime Psychiatric Base Days EB10 = Part A Lifetime Psychiatric Remaining Days Only returned if STC=45 is requested on 270 EB10 = Part A Hospice Occurrence Count N/A EB03 = "30" and applicable HETS supported Service Type Codes EB04 = "MB" DTP03 = Entitlement and Termination Dates (where applicable) N/A EB07 = Part B Base Deductible 2016 DTP03 = Calendar Year EB07 = Part B Base Deductible 2015 DTP03 = Calendar Year EB07 = Part B Remaining Deductible 2016 EB*B**AG*MA**7*0~ HSD***DA**29*18~ HSD*****26*1~ DTP*435*RD8*20160414-20160420~ EB*B**AG*MA**7*161~ HSD***DA**29*80~ HSD*****26*1~ DTP*435*RD8*20160414-20160420~ The following segments illustrate Part A Lifetime Reserve EB*K**30*MA**32***DY*60~ EB*K**30*MA**33***DY*58~ EB*K**30*MA**7*644~ DTP*435*RD8*20160101-20161231~ EB*K**30*MA**7*630~ DTP*435*RD8*20150101-20151231~ The following segments illustrate Part A Lifetime Psychiatric Limitation Data EB*K**A7*MA**32***DY*190~ EB*K**A7*MA**33***DY*180~ The following segment illustrates Part A Hospice Occurrence Count EB*D**45*MA**26***99*1~ The following segments illustrate Part B Entitlement/Coverage EB*1**30^2^3^10^14^23^24^25^26^27^28^33^36^37^38^39^40^42^50^51^52^53^67^69^73^76^83^86^98 ^A4^A6^A8^AD^AE^AF^AI^AJ^AK^AL^BF^BG^BT^BU^BV^DM^UC*MB~ DTP*291*D8*20050401~ The following segments illustrate Part B Plan Level Financial Data EB*C**30*MB**23*166~ DTP*291*RD8*20160101-20161231~ EB*C**30*MB**23*147~ DTP*291*RD8*20150101-20151231~ EB*C**30*MB**29*0~ Date of Last Revision: 06/10/2016 Page 5 271 Segment HETS Returned Values DTP*291*RD8*20160101-20161231~ EB*C**30*MB**29*0~ DTP*291*RD8*20150101-20151231~ EB*A**30*MB**27**.2~ DTP*291*RD8*20160101-20161231~ EB*A**30*MB**27**.2~ DTP*291*RD8*20150101-20151231~ The following segments illustrate Part B” Free” Services Deductible EB*C**5^42^67^AJ*MB**23*0~ DTP*292*RD8*20160101-20161231~ EB*C**5^42^67^AJ*MB**23*0~ DTP*292*RD8*20150101-20151231~ The following segments illustrate Part B “Free” Services Coinsurance EB*A**5^42^67^AJ*MB**27**0~ DTP*292*RD8*20160101-20161231~ EB*A**5^42^67^AJ*MB**27**0~ DTP*292*RD8*20150101-20151231~ The following segments illustrate Benefit Level Financial Data for Part B HCPCS codes DTP03 = Calendar Year EB07 = Part B Remaining Deductible 2015 DTP03 = Calendar Year EB08 = Part B Plan Level Coinsurance2016 DTP03 = Calendar Year EB08 = Part B Plan Level Coinsurance 2015 DTP03 = Calendar Year N/A EB07 = Part B Base Deductible is not applicable 2016 DTP03 = Calendar Year EB07 = Part B Base Deductible is not applicable 2015 DTP03 = Calendar Year N/A EB08 = Part B Co-Insurance for Part B is not applicable 2016 DTP03 = Calendar Year EB08 = Part B Co-Insurance for Part B is not applicable 2015 DTP03 = Calendar Year Example of Multiple HETS Supported HCPCS codes requested. EQ02 = 90670, G0106, G0117 EB07 = Part B Plan Applicable Deductible Amount (Waived for this service) DTP03 = Calendar year of the date when the 270 request was received EB07 = Part B Plan Applicable Deductible Amount (Waived for this service) DTP03 = Calendar year of the date when the 270 request was received EB07 = Part B Plan Applicable Base Deductible Amount DTP03 = Calendar year of the date when the 270 request was received EB07 = Part B Remaining Deductible Amount (This will not be returned if Base Deductible is waived) for this service DTP03 = Calendar year of the date when the 270 request was received EB08 = Part B Plan Applicable Coinsurance Amount (Waived for this service) DTP03 = Calendar year of the date when the 270 request was received EB08 = Part B Plan Applicable Coinsurance Amount DTP03 = Calendar year of the date when the 270 request was received EB08 = Part B Plan Applicable Coinsurance Amount DTP03 = Calendar year of the date when the 270 request was received EB*C***MB**23*0******HC|90670~ DTP*292*RD8*20160101-20161231~ EB*C***MB**23*0******HC|G0106~ DTP*292*RD8*20160101-20161231~ EB*C***MB**23*166******HC|G0117~ DTP*292*RD8*20160101-20161231~ EB*C***MB**29*0******HC|G0117~ DTP*292*RD8*20160101-20161231~ EB*A***MB**27**0*****HC|90670~ DTP*292*RD8*20160101-20161231~ EB*A***MB**27**.2*****HC|G0106~ DTP*292*RD8*20160101-20161231~ EB*A***MB**27**.2*****HC|G0117~ DTP*292*RD8*20160101-20161231~ Date of Last Revision: 06/10/2016 Page 6 271 Segment HETS Returned Values The following segments illustrate beneficiary-specific eligibility for Part B Preventive Services. EB*D***MB*********HC|90670~(Preventive HCPCS Sample) DTP*348*D8*20130101~ EB*D***MB*********HC|G0106~(Preventive HCPCS Sample) DTP*348*D8*20140625~ EB*D***MB*********HC|G0117~(Preventive HCPCS Sample) DTP*348*D8*20140625~ The following segments illustrate Part B Smoking Cessation Sessions. NOTE: HETS will return either Number of Sessions Remaining or Next Eligible Date. EB*F**67*MB**22***VS*8~ HSD*VS*6***29~ (See note above) OR DTP*348*D8*20160101~ (See note above) The following segments illustrate Part B Therapy Benefit Detail EB*D**AD*MB***1345~ DTP*292*RD8*20160101-20161231~ MSG*USED AMOUNT~ EB*D**AD*MB***200~ DTP*292*RD8*20150101-20151231~ MSG*USED AMOUNT~ EB*D**AE*MB***0~ DTP*292*RD8*20160101-20161231~ MSG*USED AMOUNT~ EB*D**AE*MB***0~ DTP*292*RD8*20150101-20151231~ MSG*USED AMOUNT~ The following segments illustrate Part B Rehabilitation Benefit Detail EB*F**BF*MB**29***CA*36~ MSG*Professional~ EB*F**BF*MB**29***CA*36~ MSG*Technical~ EB*F**BG*MB*****99*0~ MSG*Professional~ EB*F**BG*MB*****99*0~ MSG*Technical~ EB*F**BG*MB*****99*15~ EQ02 value must be requested on the 270 EB13 = Part B Preventive HCPCS Code DTP03 = Next Eligible Date for Preventive Service EB13 = Part B Preventive HCPCS Code DTP03 = Next Eligible Date for Preventive Service EB13 = Part B Preventive HCPCS Code DTP03 = Next Eligible Date for Preventive Service Only returned if STC=67 is requested on 270 Date of Last Revision: 06/10/2016 EB10 = Part B Base Number of Smoking Cessation Sessions HSD03 = Number of Smoking Cessation Sessions Remaining N/A DTP03 = Next Eligible Date for Smoking Cessation if all sessions used Only returned if Part B STC=AD, AE or AF is requested on 270 EB03 = AD for Occupational Therapy, EB07= Therapy Amount Used DTP03 = Calendar Year N/A EB03 = AD for Occupational Therapy, EB07= Therapy Amount Used DTP03 = Calendar Year N/A EB03 =AE for Physical/Speech Therapy, EB07= Therapy Amount Used DTP03 = Calendar Year N/A EB03 =AE for Physical/Speech Therapy, EB07= Therapy Amount Used DTP03 = Calendar Year N/A Only returned if Part B STC=BF or BG is requested on 270 EB10 = Number of Pulmonary Rehabilitation Sessions remaining N/A EB10 = Number of Pulmonary Rehabilitation Sessions remaining N/A EB10 = Number of Cardiac Rehabilitation Sessions used N/A EB10 = Number of Cardiac Rehabilitation Sessions used N/A EB10 = Number of Intensive Cardiac Rehabilitation Services Used only if MSG01 = Intensive Cardiac Rehabilitation Page 7 271 Segment HETS Returned Values MSG*Intensive Cardiac Rehabilitation – Professional~ EB*F**BG*MB*****99*15~ N/A EB10 = Number of Intensive Cardiac Rehabilitation Services Used only if MSG01 = Intensive Cardiac Rehabilitation N/A Only returned if Part A/B STC=42 is requested on 270 N/A DTP03 = Home Health Period Start & End Dates DTP03 = Home Health Period DOEBA DTP03 = Home Health Period DOLBA N/A NM103 = Home Health Contractor Name NM109 = Home Health Contractor Number NM109 = Home Health Service Provider NPI N/A EB13 = Home Health Certification HCPC DTP03 = Home Health Certification Start Date EB13 = Home Health Recertification HCPC DTP03 = Home Health Recertification Date DTP03 = Home Health Recertification Date Only returned if Part A STC=45 is requested on 270 N/A DTP03 = Hospice Period Date(s) MSG01 = “Revocation Code “ + Hospice Revocation Code N/A NM109 = Hospice Provider NPI N/A Only returned if Part B STC=14 or 15 is requested on 270 EB03 = 14 for Dialysis performed at home or in an outpatient facility DTP03 = ESRD Dialysis Method Start Date DTP03 = Kidney Transplant Hospital Discharge Date N/A EB03 = 15 for Dialysis performed as a part of an Inpatient stay DTP03 = ESRD Dialysis Method Start Date DTP03 = Kidney Transplant Hospital Discharge Date Only returned if STC=10 is requested on 270 EB10 = Number of Fully Covered Units HSD02 = Number of Units Remaining MSG*Intensive Cardiac Rehabilitation – Technical~ The following segments illustrate Home Health (Cert /Recert dates each limited to 10 occurrences) EB*X**42***26~ DTP*472*RD8*20150522-20150929~ DTP*193*D8*20150522 DTP*194*D8*20150929 LS*2120~ NM1*PR*2*ORGNAME*****PI*CONTR~ NM1*1P*2******XX*1234567890~ LE*2120~ EB*X************HC|G0180~ DTP*193*D8*20150521~ EB*X************HC|G0179~ DTP*193*D8*20150917~ DTP*193*D8*20150719~ The following segments illustrate Part A Hospice Episodes EB*X**45*MA**26~ DTP*292*RD8*20151115-20151205~ MSG*Revocation Code - 1~ LS*2120~ NM1*1P*2******XX*1234567890~ LE*2120~ The following segments illustrate Part B ESRD data EB*D**14*MB~ DTP*356*D8*20110601~ DTP*096*D8*20130105~ OR EB*D**15*MA~ DTP*356*D8*20110601~ DTP*096*D8*20130105~ The following segments illustrate Blood Deductible Data EB*E**10***23***DB*3~ HSD*FL*2***29~ Date of Last Revision: 06/10/2016 Page 8 271 Segment HETS Returned Values DTP*292*RD8*20160101-20161231~ EB*E**10***23***DB*3~ HSD*FL*1***29~ DTP*292*RD8*20150101-20151231~ The following segments illustrate Part D Enrollment EB*R**88*OT~ REF*18*S0000 999~ DTP*292*D8*20130101~ LS*2120~ NM1*PR*2*ORGNAME~ N3*ADDRESSLINE1*ADDRESSLINE2~ N4*CITY*ST*ZIPCODE~ PER*IC**TE*AAABBBCCCC*UR*www.website.com~ DTP03 = Calendar year EB10 = Number of Fully Covered Units HSD02 = Number of Units Remaining DTP03 = Calendar year N/A N/A REF02 = Part D Contract Number + “ “ + PBP Number DTP03 = Part D Plan Enrollment Date(s) N/A NM103 = Part D Contract Name N301/N302 = Part D Contract Address N401/N402/N403 = Part D Contract City/State/ZIP PER04 = Part D Plan Telephone Number PER06 = Contract Website Address N/A N/A EB04 = MCO Contract Type (HMO, PPO, Indemnity, etc.) REF02 = MCO Contract Number +” “ + PBP Number DTP03 = MCO Plan Enrollment Date(s) MSG01 = “MCO Bill Option Code –“ +” ” + Bill Option Code N/A NM103 = MCO Contract Name N301/N302 = MCO Contract Address N401/N402/N403 = MCO Contract City/State/ZIP PER04 = MCO Plan Telephone Number PER06 = MCO Plan Website Address N/A N/A EB04 = MSP Insurance Type Code REF02 = Insurance Policy Number DTP03 = MSP Effective Date(s) N/A NM103 = MSP Name N301/N302 = MSP Insurance Address N401 = MSP City, N402=MSP State, N403=MSP Zip N/A N/A LE*2120~ The following segments illustrate Part C MCO (Medicare Advantage) enrollment EB*R**30*IN~ REF*18*H0000 999~ DTP*290*D8*20090101~ MSG*MCO Bill Option Code- C~ LS*2120~ NM1*PRP*2*ORGNAME~ N3*ADDRESSLINE1*ADDRESSLINE2~ N4*CITY*ST*ZIPCODE~ PER*IC**TE*AAABBBCCCC*UR*www.website.com~ LE*2120~ The following segments illustrate MSP Enrollment EB*R**30*13~ REF*IG*POLICYNUMBER~ DTP*290*RD8*20130701-20160401~ LS*2120~ NM1*PRP*2*ORGNAME~ N3*ADDRESSLINE1*ADDRESSLINE2~ N4*CITY*ST*ZIPCODE~ LE*2120~ The following segments illustrate the end of a transaction. Date of Last Revision: 06/10/2016 Page 9 271 Segment HETS Returned Values SE*233*0001~ GE*1*1~ IEA*1*111111111~ N/A N/A N/A Date of Last Revision: 06/10/2016 Page 10
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.5 Linearized : No Author : CMS Company : FEi Systems Create Date : 2016:06:13 16:14:52-04:00 Keywords : HETS, Sample, 271, Response Modify Date : 2016:06:13 16:15:31-04:00 Source Modified : D:20160613201446 Subject : Sample HETS 271 response Language : EN-US Tagged PDF : Yes XMP Toolkit : Adobe XMP Core 5.4-c005 78.147326, 2012/08/23-13:03:03 Metadata Date : 2016:06:13 16:15:31-04:00 Creator Tool : Acrobat PDFMaker 11 for Word Document ID : uuid:d188edd3-8c71-44be-97fe-d46e838762d7 Instance ID : uuid:33f75381-cf3c-4550-9f4f-0eb6d783cd87 Format : application/pdf Title : Medicare 271 Transaction Example using the HETS Application Description : Sample HETS 271 response Creator : CMS Producer : Adobe PDF Library 11.0 Headline : Sample HETS 271 response Page Layout : OneColumn Page Count : 10EXIF Metadata provided by EXIF.tools