Medicare Secondary Payer context

Scenario

This example uses a Medicare Secondary Payer scenario with a subscriber, benefit statement, and date. The label helps explain coordination concepts; the message was written for this guide and was not returned by CMS HETS. Scenario labels do not establish payer order. Use the actual response, payer or plan records, and applicable route rules when determining coverage order.

Complete response

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ISA*00*          *00*          *ZZ*HARBORPOINTHP  *ZZ*MAPLEGROVEFC   *990102*1202*^*00501*000000202*0*P*:~
GS*HB*HARBORPOINTHP*MAPLEGROVEFC*20990101*1202*202*X*005010X279A1~
ST*271*0202*005010X279A1~
BHT*0022*11*ELIG2020001*20990101*1202~
HL*1**20*1~
NM1*PR*2*HARBOR POINT HEALTH PLAN~
HL*2*1*21*1~
NM1*1P*2*MAPLE GROVE FAMILY CLINIC~
HL*3*2*22*0~
NM1*IL*1*BENNETT*CASEY~
EB*1**30**MEDICARE SECONDARY PLAN~
DTP*291*D8*20990101~
SE*11*0202~
GE*1*202~
IEA*1*000000202~

Segment breakdown

The entries below follow the source order. Empty fields are shown as(empty); fields not present in a source segment are not added. Stedi links identify public field references; the licensed X279A1 implementation guide supplies the complete transaction rules.

Interchange 1

• 1. ISA
• 2. GS
• 3. ST
• 4. BHT
• 5. HL
• 6. NM1
• 7. HL
• 8. NM1
• 9. HL
• 10. NM1
• 11. EB
• 12. DTP
• 13. SE
• 14. GE
• 15. IEA

1. ISA

   Raw segment: ISA*00* *00* *ZZ*HARBORPOINTHP *ZZ*MAPLEGROVEFC *990102*1202*^*00501*000000202*0*P*:~

   Opens an interchange and establishes its fixed control and delimiter positions. Its control number is 000000202.

   ISA fields

   Position	Raw value	Field name	Explanation
   ISA01	00	Authorization Information Qualifier	Identifies the format of the authorization information. The value 00 means no authorization information is present.
   ISA02	(blank: 10 spaces)	Authorization Information	Carries the authorization value; this example leaves the fixed-width value blank.
   ISA03	00	Security Information Qualifier	Identifies the format of the security information. The value 00 means no security information is present.
   ISA04	(blank: 10 spaces)	Security Information	Carries the security value; this example leaves the fixed-width value blank.
   ISA05	ZZ	Interchange ID Qualifier	Identifies the type of sender identifier. The value ZZ identifies a mutually defined sender identifier.
   ISA06	HARBORPOINTHP	Interchange Sender ID	Identifies the sender of this interchange.
   ISA07	ZZ	Interchange ID Qualifier	Identifies the type of receiver identifier. The value ZZ identifies a mutually defined receiver identifier.
   ISA08	MAPLEGROVEFC	Interchange Receiver ID	Identifies the receiver of this interchange.
   ISA09	990102	Interchange Date	Records the interchange date in YYMMDD format.
   ISA10	1202	Interchange Time	Records the interchange time in HHMM format.
   ISA11	^	Repetition Separator	Separates repeated composite values in this interchange.
   ISA12	00501	Interchange Control Version Number	Identifies the interchange control version, 00501 here.
   ISA13	000000202	Interchange Control Number	Identifies this interchange and must match IEA02.
   ISA14	0	Acknowledgment Requested	Indicates whether an interchange acknowledgment is requested. The value 0 means no interchange acknowledgment is requested.
   ISA15	P	Interchange Usage Indicator	Indicates whether the interchange is for test, production, or information data. The value P is the code for production data.
   ISA16	:	Component Element Separator	Separates component values within a composite element.

   Field reference: Stedi ISA segment reference.

2. GS

   Raw segment: GS*HB*HARBORPOINTHP*MAPLEGROVEFC*20990101*1202*202*X*005010X279A1~

   Opens a functional group inside the interchange. Its group control number is 202.

   GS fields

   Position	Raw value	Field name	Explanation
   GS01	HB	Functional Identifier Code	Identifies a group of application-related transaction sets. The value HB means Eligibility, Coverage or Benefit Information.
   GS02	HARBORPOINTHP	Application Sender's Code	Identifies the party sending the transmission.
   GS03	MAPLEGROVEFC	Application Receiver's Code	Identifies the party receiving the transmission.
   GS04	20990101	Date	Records the functional group date.
   GS05	1202	Time	Records the functional group time.
   GS06	202	Group Control Number	Identifies this group and must match GE02.
   GS07	X	Responsible Agency Code	Identifies the agency responsible for the implementation convention. The value X identifies the responsible agency as X12.
   GS08	005010X279A1	Version / Release / Industry Identifier Code	Identifies the implementation convention used by the group.

   Field reference: Stedi GS segment reference.

3. ST

   Raw segment: ST*271*0202*005010X279A1~

   Opens a transaction set inside the functional group. This transaction is 271 with control number 0202.

   ST fields

   Position	Raw value	Field name	Explanation
   ST01	271	Transaction Set Identifier Code	Identifies this response as transaction set 271. The value 271 identifies an eligibility, coverage, or benefit response.
   ST02	0202	Transaction Set Control Number	Identifies this transaction and must match SE02.
   ST03	005010X279A1	Implementation Convention Reference	Identifies the implementation convention used by the transaction.

   Field reference: Stedi ST segment reference.

4. BHT

   Raw segment: BHT*0022*11*ELIG2020001*20990101*1202~

   Supplies beginning-of-hierarchical-transaction context.

   BHT fields

   Position	Raw value	Field name	Explanation
   BHT01	0022	Hierarchical Structure Code	Identifies the hierarchical structure used by the transaction. The value 0022 means Information Source, Information Receiver, Subscriber, Dependent.
   BHT02	11	Transaction Set Purpose Code	States the purpose of this transaction set. The value 11 means Response.
   BHT03	ELIG2020001	Reference Identification	Provides the transaction reference used in this response.
   BHT04	20990101	Date	Records the date the transaction was created in the business application.
   BHT05	1202	Time	Records the time the transaction was created in the business application.

   Field reference: Stedi BHT segment reference.

5. HL

   Raw segment: HL*1**20*1~

   Establishes one hierarchical level and its optional parent relationship. This level is 1 at the top of the hierarchy.

   HL fields

   Position	Raw value	Field name	Explanation
   HL01	1	Hierarchical ID Number	Identifies this hierarchy level.
   HL02	(empty)	Hierarchical Parent ID Number	Identifies the parent level; an empty value marks the top level.
   HL03	20	Hierarchical Level Code	Identifies the kind of entity represented by this level. The value 20 identifies an information-source hierarchy level.
   HL04	1	Hierarchical Child Code	Indicates whether this level has subordinate levels. The value 1 indicates that this level has child levels.

   Field reference: Stedi HL segment reference.

6. NM1

   Raw segment: NM1*PR*2*HARBOR POINT HEALTH PLAN~

   Identifies the party attached to the current hierarchy level.

   NM1 fields

   Position	Raw value	Field name	Explanation
   NM101	PR	Entity Identifier Code	Identifies the party role represented by this name loop. The value PR identifies the payer party.
   NM102	2	Entity Type Qualifier	Identifies whether the party is an individual or organization. The value 2 identifies an organization.
   NM103	HARBOR POINT HEALTH PLAN	Name Last or Organization Name	Supplies the party name used in this response.

   Field reference: Stedi NM1 segment reference.

7. HL

   Raw segment: HL*2*1*21*1~

   Establishes one hierarchical level and its optional parent relationship. This level is 2 under parent 1.

   HL fields

   Position	Raw value	Field name	Explanation
   HL01	2	Hierarchical ID Number	Identifies this hierarchy level.
   HL02	1	Hierarchical Parent ID Number	Identifies the parent level; an empty value marks the top level.
   HL03	21	Hierarchical Level Code	Identifies the kind of entity represented by this level. The value 21 identifies an information-receiver hierarchy level.
   HL04	1	Hierarchical Child Code	Indicates whether this level has subordinate levels. The value 1 indicates that this level has child levels.

   Field reference: Stedi HL segment reference.

8. NM1

   Raw segment: NM1*1P*2*MAPLE GROVE FAMILY CLINIC~

   Identifies the party attached to the current hierarchy level.

   NM1 fields

   Position	Raw value	Field name	Explanation
   NM101	1P	Entity Identifier Code	Identifies the party role represented by this name loop. The value 1P identifies the provider party.
   NM102	2	Entity Type Qualifier	Identifies whether the party is an individual or organization. The value 2 identifies an organization.
   NM103	MAPLE GROVE FAMILY CLINIC	Name Last or Organization Name	Supplies the party name used in this response.

   Field reference: Stedi NM1 segment reference.

9. HL

   Raw segment: HL*3*2*22*0~

   Establishes one hierarchical level and its optional parent relationship. This level is 3 under parent 2.

   HL fields

   Position	Raw value	Field name	Explanation
   HL01	3	Hierarchical ID Number	Identifies this hierarchy level.
   HL02	2	Hierarchical Parent ID Number	Identifies the parent level; an empty value marks the top level.
   HL03	22	Hierarchical Level Code	Identifies the kind of entity represented by this level. The value 22 identifies a subscriber hierarchy level.
   HL04	0	Hierarchical Child Code	Indicates whether this level has subordinate levels. The value 0 indicates that this level has no child levels.

   Field reference: Stedi HL segment reference.

10. NM1

    Raw segment: NM1*IL*1*BENNETT*CASEY~

    Identifies the party attached to the current hierarchy level.

    NM1 fields

    Position	Raw value	Field name	Explanation
    NM101	IL	Entity Identifier Code	Identifies the party role represented by this name loop. The value IL identifies the insured or subscriber party.
    NM102	1	Entity Type Qualifier	Identifies whether the party is an individual or organization. The value 1 identifies an individual person.
    NM103	BENNETT	Name Last or Organization Name	Supplies the party name used in this response.
    NM104	CASEY	Name First	Supplies the person’s first name when present.

    Field reference: Stedi NM1 segment reference.

11. EB

    Raw segment: EB*1**30**MEDICARE SECONDARY PLAN~

    Reports one qualified eligibility or benefit statement in the current subscriber context. Its status is 1 and its service type is 30.

    EB fields

    Position	Raw value	Field name	Explanation
    EB01	1	Eligibility or Benefit Information Code	States the eligibility or benefit status represented by this statement. The value 1 means Active Coverage.
    EB02	(empty)	Coverage Level Code	Identifies the coverage level when supplied.
    EB03	30	Service Type Code	Identifies the service type covered by this statement. The value 30 identifies health benefit plan coverage as the service type.
    EB04	(empty)	Insurance Type Code	Identifies the insurance type when supplied.
    EB05	MEDICARE SECONDARY PLAN	Plan Coverage Description	Provides the plan or coverage description used in this response.

    Field reference: Stedi EB segment reference.

12. DTP

    Raw segment: DTP*291*D8*20990101~

    Supplies a date or date period related to the current benefit context.

    DTP fields

    Position	Raw value	Field name	Explanation
    DTP01	291	Date/Time Qualifier	Identifies what the date represents. The value 291 means Plan (date/range for which plan is in effect).
    DTP02	D8	Date Time Period Format Qualifier	Identifies the format of the date value. The value D8 identifies a single date in CCYYMMDD format.
    DTP03	20990101	Date Time Period	Supplies the date or date period.

    Field reference: Stedi DTP segment reference.

13. SE

    Raw segment: SE*11*0202~

    Closes a transaction set and declares its segment count. It closes transaction 0202.

    SE fields

    Position	Raw value	Field name	Explanation
    SE01	11	Number of Included Segments	Counts segments from ST through SE.
    SE02	0202	Transaction Set Control Number	Matches ST02 for this transaction.

    Field reference: Stedi SE segment reference.

14. GE

    Raw segment: GE*1*202~

    Closes a functional group and declares its transaction count. It closes group 202.

    GE fields

    Position	Raw value	Field name	Explanation
    GE01	1	Number of Transaction Sets Included	Counts transaction sets in this functional group.
    GE02	202	Group Control Number	Matches GS06 for this functional group.

    Field reference: Stedi GE segment reference.

15. IEA

    Raw segment: IEA*1*000000202~

    Closes an interchange and declares its group count. It closes the interchange with control number 000000202.

    IEA fields

    Position	Raw value	Field name	Explanation
    IEA01	1	Number of Included Functional Groups	Counts functional groups in this interchange.
    IEA02	000000202	Interchange Control Number	Matches ISA13 for this interchange.

    Field reference: Stedi IEA segment reference.

Sources

• CMS-MSP supports Medicare Secondary Payer program context.
• X12-EXAMPLES-005010X279 supports the public 271 pattern and hierarchy examples.
• STEDI-271-GUIDE, STEDI-EB, STEDI-DTP, and STEDI-NM1 provide public cross-references.