Files > INSURANCE VERIFICATION PROCESSOR

name

INSURANCE VERIFICATION PROCESSOR

number

355.33

location

^IBA(355.33,

description

This file contains insurance information accumulated by various sources. The data is held in this file until an authorized person processes the information by either rejecting it or moving it to the Insurance files. Once an entry is processed most of the data is deleted leaving a stub entry in this file which can be used for reporting and tracking purposes.

Fields

#	Name	Location	Type	Details	Index	Description
.01	date entered(+)	0;1	DATE-TIME		B	This is the date this entry is added to the buffer file.
.02	entered by	0;2	POINTER	200		This is the user of the source package that entered this insurance entry.
.03	source of information	0;3	POINTER	355.12		This is the source by which this insurance information was obtained.
.04	status	0;4	SET OF CODES	E:ENTERED A:ACCEPTED R:REJECTED		This is the status of this insurance entry. E - Entered Locally but not yet processed A - Processed and Accepted, data moved to Insurance files R - Processed and Rejected, data Not moved to Insurance files When an entry is processed most of the data is deleted from the Insurance Buffer file. Entries with a status of Accepted or Rejected will only have stub entries in this file for reporting and tracking purposes.
.05	date processed	0;5	DATE-TIME			This is the date authorized insurance personnel either accepted or rejected the information in this entry.
.06	processed by	0;6	POINTER	200		This is the insurance user who accepted or rejected this entry.
.07	new company	0;7	BOOLEAN	1:YES 0:NO		This flag indicates if this buffer entry resulted in a new Insurance Company being created. This will only be Yes if the buffer entry was accepted and a new Insurance Company entry was added to the Insurance Company File.
.08	new group/plan	0;8	BOOLEAN	1:YES 0:NO		This flag indicates if this buffer entry resulted in a new Group/Plan being created. This will only be Yes if the buffer entry was accepted and a new Group/Plan entry was added to the Group Insurance Plan file.
.09	new policy	0;9	BOOLEAN	1:YES 0:NO		This flag indicates if this buffer entry resulted in a new Patient Insurance Policy being created. This will only be Yes if the buffer entry was accepted and a new Policy entry was added for this patient.
.1	date verified	0;10	DATE-TIME			This is the date insurance personnel verified this insurance information is correct. This will only be used if the verification step was completed separately from the acceptance step of the process.
.11	verified by	0;11	POINTER	200		This is the insurance user that verified this insurance information is correct. This should only be entered if the entry is verified before it is accepted.
.12	iiv status	0;12	POINTER	365.15		This field is a pointer to the IIV STATUS TABLE file. This identifies the visual symbol that should appear in the IIV status column in the insurance buffer listing of entries. The symbols appear next to the patient name to indicate the current stage within the electronic verification process.
.13	override freshness flag	0;13	BOOLEAN	1:YES 0:NO		The presence of this flag will alert the Buffer extract process and also the process that electronically transmits the insurance verification request, that this buffer entry should get transmitted and sent to the Payer - bypassing the National Insurance Cache. This is regardless of the freshness date or of any other data elements. This flag trumps everything else in the electronic verification process.
.14	remote location	0;14	POINTER	4		This is the remote location from where this insurance information was gathered from. This field is optional and will only be completed if the information came from a remote facility.
.15	iiv processed date	0;15	DATE-TIME			This date/time field is automatically updated when a response is received using the electronic insurance eligibility communications via the IIV software.
.16	real time verification	0;16	BOOLEAN	0:NO 1:YES		Flag that indicates if Real Time Verification processed and verified this insurance buffer entry.
.17	bps response	0;17	POINTER	9002313.03	E	This is the payer's response to an Eligibility Inquiry. When an ePharmacy Eligibility Inquiry transaction is sent to the payer, the payer responds with an NCPDP Eligibility Response transaction through the ECME engine. This response is stored by default in the BPS RESPONSES file. When this happens an insurance buffer entry is also created. This field links the buffer entry with the BPS Response entry.
.18	service date	0;18	DATE-TIME			Service date to be included in eIV inquiry.
20.01	insurance company name	20;1	FREE TEXT		D	Enter the name of the Insurance Carrier that provides coverage for this patient.
20.02	phone number	20;2	FREE TEXT			Enter the phone number at which this insurance company can be reached.
20.03	billing phone number	20;3	FREE TEXT			The insurance carriers phone number where inquires about patient billing should be made.
20.04	precertification phone number	20;4	FREE TEXT			If this company requires pre-certification of insurance coverage to be completed prior to a patient being treated then enter the phone number of the pre-cert office.
20.05	reimburse?	20;5	SET OF CODES	Y:WILL REIMBURSE *:WILL REIMBURSE IF TREATED UNDER VAR 6046(C) OR VAR 6060.2(A) **:DEPENDS ON POLICY, CHECK WITH COMPANY N:WILL NOT REIMBURSE		Choose from the available list of choices the appropriate code denoting whether or not and under which circumstances this insurance carrier will reimburse the Dept of Veterans Affairs for care received.
21.01	street address [line 1]	21;1	FREE TEXT			Enter the first line of the insurance company's mailing address street.
21.02	street address [line 2]	21;2	FREE TEXT			If the insurance company's mailing address street is longer than 1 line, enter the second line here.
21.03	street address [line 3]	21;3	FREE TEXT			If the insurance company's mailing address street is longer than 2 lines, enter the third line here.
21.04	city	21;4	FREE TEXT			This is the insurance company's mailing address city.
21.05	state	21;5	POINTER	5		This is the insurance company's mailing address state.
21.06	zip code	21;6	FREE TEXT			This is the insurance company's mailing address zip code.
40.01	is this a group policy?	40;1	BOOLEAN	1:YES 0:NO		Some policies are individual policies and are specific to a patient. Many policies are group plans that cover many patients.
40.02	*group name	40;2	FREE TEXT			This is the name that the insurance company uses to identify this plan. This field is scheduled for deletion in May 2015.
40.03	*group number	40;3	FREE TEXT			This is the number or code which the insurance company uses to identify this plan. This field is scheduled for deletion in May 2015.
40.04	utilitzation review required	40;4	BOOLEAN	1:YES 0:NO		If this is answered Yes, then the UR staff will be required to follow-up on all billable cases. If this is answered No then UR follow-up will be considered optional.
40.05	precertification required	40;5	BOOLEAN	1:YES 0:NO		Enter Yes if this plan requires all non-emergent admissions to be pre-certified.
40.06	ambulatory care certification	40;6	BOOLEAN	1:YES 0:NO		Enter Yes if this plan requires certification of ambulatory procedures. This may include Ambulatory Surgeries, CAT Scans, MRI, non-invasive procedures, etc.
40.07	exclude preexisting condition	40;7	BOOLEAN	1:YES 0:NO		Enter Yes if the plan does not cover any pre-existing conditions the patient may have, otherwise enter No.
40.08	benefits assignable	40;8	BOOLEAN	1:YES 0:NO		Enter Yes if assignment of benefits is allowed by this plan.
40.09	type of plan	40;9	POINTER	355.1		Select the Type of Plan that best describes this plan. The Type of Plan may be used to determine if reimbursement for claims from the insurance carrier is appropriate.
40.1	banking identification number	40;10	FREE TEXT			The Plan's Banking Identification Number (BIN). Used for NCPDP transmissions.
40.11	processor control number (pcn)	40;11	FREE TEXT			The Plan's Processor Control Number (PCN). Used for NCPDP transmissions.
60.01	patient name	60;1	POINTER	2	C	This is the patient covered by this insurance policy.
60.02	effective date	60;2	DATE-TIME			This is the date this policy went into effect for this patient.
60.03	expiration date	60;3	DATE-TIME			If this insurance policy coverage expires for this patient on a specified date, enter that date, otherwise leave this blank.
60.04	*subscriber id	60;4	FREE TEXT			Enter the Subscriber's Primary ID number. This number is assigned by the payer and can be found on the subscriber's insurance card. This field is scheduled for deletion in May 2015.
60.05	whose insurance	60;5	SET OF CODES	v:VETERAN s:SPOUSE o:OTHER p:PATIENT		Enter 'v' if this insurance policy is held by the veteran, 's' if the veterans spouse holds the policy, or 'o' if anyone else is the policy holder.
60.06	pt. relationship to insured	60;6	SET OF CODES	01:PATIENT 02:SPOUSE 03:NATURAL CHILD 08:EMPLOYEE 09:DO NOT USE 11:ORGAN DONOR 15:INJURED PLANTIFF 18:DO NOT USE 32:MOTHER 33:FATHER 34:SIGNIFICANT OTHER 35:LIFE PARTNER 36:OTHER RELATIONSHIP		Enter the code which best describes the patient's relationship to the person who holds this policy (or insured).
60.07	*name of insured	60;7	FREE TEXT			Enter the name of the individual for which this policy was issued. If the Patients Relationship to the Insured is 'Patient' then this name will default to the patients name via input transform. This field is scheduled for deletion in May 2015.
60.08	insured's dob	60;8	DATE-TIME			This is the policy holder's (insured's) Date of Birth. This is not needed if the patient is not the policy holder since the patient's DOB is stored elsewhere.
60.09	insured's ssn	60;9	FREE TEXT			This is the policy holders (insured's) social security number. This only needs to be entered if it is different than the Subscriber Id number and the insured is not the patient.
60.1	primary care provider	60;10	FREE TEXT			This is the patient's Primary Care Provider within their managed care network that referred the patient to the VA. In some cases if the patients PC Provider refers the patient to the VA their HMO will reimburse.
60.11	primary provider phone	60;11	FREE TEXT			This is the phone number of the patients non-VA primary care provider that may refer the patient to the VA for care.
60.12	coordination of benefits	60;12	SET OF CODES	1:PRIMARY 2:SECONDARY 3:TERTIARY		Enter '1' if this is the patient's primary insurance policy. Enter '2' if this policy is secondary to (billed after) the primary policy. Enter '3' if this policy is tertiary or billed after the secondary policy.
60.13	insured's sex	60;13	SET OF CODES	F:FEMALE M:MALE		This field is used in insurance billing to help verify the policy coverage when the bill is submitted to the carrier. If the patient is the policy holder, this value should match the patient's sex. If the patient's spouse or other relative is the policy holder, the appropriate value should be determined and entered.
60.14	pt. relationship - hipaa	60;14	SET OF CODES	01:SPOUSE 18:SELF 19:CHILD 20:EMPLOYEE 29:SIGNIFICANT OTHER 32:MOTHER 33:FATHER 39:ORGAN DONOR 41:INJURED PLAINTIFF 53:LIFE PARTNER G8:OTHER RELATIONSHIP		Select the HIPAA relationship code that describes the relationship this patient has to the holder of this insurance policy. If the policy belongs to the patient enter '18' for SELF. If the policy belongs to the spouse enter '01' for SPOUSE, etc.
60.15	pharmacy relationship code	60;15	POINTER	9002313.19		This is the relationship of the patient to the cardholder. Code Description ---- ----------- 0 Not Specified 1 Cardholder - The individual that is enrolled in and receives benefits from a health plan 2 Spouse - Patient is the husband/wife/partner of the cardholder 3 Child - Patient is a child of the cardholder 4 Other - Relationship to cardholder is not precise
60.16	pharmacy person code	60;16	FREE TEXT			This is the code that is assigned by the payer to identify the patient. The payer may use a unique person code to identify each specific person on the pharmacy insurance policy. This code may also describe the patient's relationship to the cardholder. Enrollment Standard Examples: 001 = Cardholder 002 = Spouse 003 - 999 = Dependents and Others (including second spouses, etc.)
61.01	esghp?	61;1	BOOLEAN	1:YES 0:NO		Enter Yes if this policy is part of a plan that is sponsored or provided by the insured's (policy holder's) current or past employer.
61.02	sponsoring employer name	61;2	FREE TEXT			If this is an Employer Sponsored Group Health Plan then enter the name of the employer that sponsors the plan.
61.03	employment status	61;3	SET OF CODES	1:FULL TIME 2:PART TIME 3:NOT EMPLOYED 4:SELF EMPLOYED 5:RETIRED 6:ACTIVE MILITARY 9:UNKNOWN		If this plan is an Employer Sponsored Group Health Plan then enter the policy holders employment status with the sponsoring employer.
61.04	retirement date	61;4	DATE-TIME			If this plan is an Employer Sponsored Group Health Plan then enter the date the insured retired from the employer that sponsors the plan.
61.05	send bill to employer	61;5	BOOLEAN	1:YES 0:NO		If this is an Employer Sponsored Group Health Plan and the sponsoring employer requires claims against the policy be sent first to them for pre-processing, rather than the insurance company, then enter Yes. You will then be able to enter an address that these bills should be sent to. If the employer does not require this then the bills will be sent directly to the insurance company.
61.06	employer claims street line 1	61;6	FREE TEXT			Enter the first line of the street address of the sponsoring employers claims office if this is an Employer Sponsored Group Health Plan and the sponsoring employer requires claims against the policy be sent to them for pre-processing.
61.07	employer claims street line 2	61;7	FREE TEXT			Enter the second line of the street address of the sponsoring employers claims office if this is an Employer Sponsored Group Health Plan and the sponsoring employer requires claims against the policy be sent to them for pre-processing.
61.08	employer claims street line 3	61;8	FREE TEXT			Enter the third line of the street address of the sponsoring employers claims office if this is an Employer Sponsored Group Health Plan and the sponsoring employer requires claims against the policy be sent to them for pre-processing.
61.09	employer claims city	61;9	FREE TEXT			Enter the city of the sponsoring employers claims office if this is an Employer Sponsored Group Health Plan and the sponsoring employer requires claims against the policy be sent to them for pre-processing.
61.1	employer claims state	61;10	POINTER	5		Enter the State of the sponsoring employers claims office if this is an Employer Sponsored Group Health Plan and the sponsoring employer requires claims against the policy be sent to them for pre-processing.
61.11	employer claims zip code	61;11	FREE TEXT			Enter the zip code of the sponsoring employers claims office if this is an Employer Sponsored Group Health Plan and the sponsoring employer requires claims against the policy be sent to them for pre-processing.
61.12	employer claims phone number	61;12	FREE TEXT			Enter the phone number of the sponsoring employers claims office if this is an Employer Sponsored Group Health Plan and the sponsoring employer requires claims against the policy be sent to them for pre-processing.
62.01	patient id	62;1	FREE TEXT			This is the patient's primary ID number for this insurance company. Enter this field when the patient and the subscriber are different and the patient has a unique ID number.
62.02	subscriber address line 1	62;2	FREE TEXT			Subscriber address, line 1.
62.03	subscriber address line 2	62;3	FREE TEXT			Subscriber address, line 2.
62.04	subscriber address city	62;4	FREE TEXT			Subscriber address, city.
62.05	subscriber address state	62;5	POINTER	5		Subscriber address, state.
62.06	subscriber address zip	62;6	FREE TEXT			Subscriber address, zip code.
62.07	subscriber address country	62;7	FREE TEXT			Subscriber address, country code.
62.08	subscriber address subdivision	62;8	FREE TEXT			Subscriber address, country subdivision code.
80.01	inq service type code 1	80;1	POINTER	365.013		First Service Type Code to be sent with eIV insurance inquiry.
80.02	inq service type code 2	80;2	POINTER	365.013		Second Service Type Code to be sent with eIV Insurance Inquiry.
80.03	inq service type code 3	80;3	POINTER	365.013		Third Service Type Code to be sent with eIV Insurance Inquiry.
80.04	inq service type code 4	80;4	POINTER	365.013		Fourth Service Type Code to be sent with eIV Insurance Inquiry.
80.05	inq service type code 5	80;5	POINTER	365.013		Fifth Service Type Code to be sent with eIV Insurance Inquiry.
80.06	inq service type code 6	80;6	POINTER	365.013		Sixth Service Type Code to be sent with eIV Insurance Inquiry.
80.07	inq service type code 7	80;7	POINTER	365.013		Seventh Service Type Code to be sent with eIV Insurance Inquiry.
80.08	inq service type code 8	80;8	POINTER	365.013		Eighth Service Type Code to be sent with eIV Insurance Inquiry.
80.09	inq service type code 9	80;9	POINTER	365.013		Ninth Service Type Code to be sent with eIV Insurance Inquiry.
80.1	inq service type code 10	80;10	POINTER	365.013		Tenth Service Type Code to be sent with eIV Insurance Inquiry.
80.11	inq service type code 11	80;11	POINTER	365.013		Eleventh Service Type Code to be sent with eIV Insurance Inquiry.
80.12	inq service type code 12	80;12	POINTER	365.013		Twelfth Service Type Code to be sent with eIV Insurance Inquiry.
80.13	inq service type code 13	80;13	POINTER	365.013		Thirteenth Service Type Code to be sent with eIV Insurance Inquiry.
80.14	inq service type code 14	80;14	POINTER	365.013		Fourteenth Service Type Code to be sent with eIV Insurance Inquiry.
80.15	inq service type code 15	80;15	POINTER	365.013		Fifteenth Service Type Code to be sent with eIV Insurance Inquiry.
80.16	inq service type code 16	80;16	POINTER	365.013		Sixteenth Service Type Code to be sent with eIV Insurance Inquiry.
80.17	inq service type code 17	80;17	POINTER	365.013		Seventeenth Service Type Code to be sent with eIV Insurance Inquiry.
80.18	inq service type code 18	80;18	POINTER	365.013		Eighteenth Service Type Code to be sent with eIV Insurance Inquiry.
80.19	inq service type code 19	80;19	POINTER	365.013		Nineteenth Service Type Code to be sent with eIV Insurance Inquiry.
80.2	inq service type code 20	80;20	POINTER	365.013		Twentieth Service Type Code to be sent with eIV Insurance Inquiry.
90.01	group name	90;1	FREE TEXT			This is the name that the insurance company uses to identify this plan.
90.02	group number	90;2	FREE TEXT			This is the number or code which the insurance company uses to identify this plan.
90.03	subscriber id	90;3	FREE TEXT			Enter the Subscriber's Primary ID number. This number is assigned by the payer and can be found on the subscriber's insurance card.
91.01	name of insured	91;1	FREE TEXT			This is the name of the individual for which this policy was issued. If the Patient Relationship to the Insured is 'Patient' then this name will default to the patient name via input transform.