Medicare Pre-HIPAA EDI Formats

Medicare carriers, MACs, FIs, and RHHIs will not be involved in Medicare acceptance and processing of the X12N 270/271 IG version 004010A1 transactions for Beneficiary Eligibility Inquiry & Response but information on that transaction is available at www.cms.hhs.gov/ElectronicBillingEDITrans/09_Eligibility.asp. The 270 transaction will be accepted and processed, and a 271 returned by a CMS Enterprise Data Center (EDC) directly. See Chapter 31 of this manual for further information.

Pending termination of the Medicare contingency plan for the HIPAA eligibility standard transaction, carriers, MACs, FIs and RHHIs are required to temporarily continue to support use of the following pre-HIPAA electronic transaction formats until the earlier of the effective date for CMS elimination of the HIPAA eligibility contingency plan, or the date when no further providers, billing agents, or clearinghouses are using a non-HIPAA electronic eligibility format:

•    X12N 270/271 IG version 003051 for eligibility query and response (carriers only); and

•    Proprietary format for eligibility data responses using the CMS standard eligibility data set.

See Chapter 31of this manual for additional information on eligibility queries. Specifications for the X12 270/271 version 3051 can be found on the Washington Publishing Company Web site at http://www.wpc-edi.com/HIPAA.

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