Eligibility Message Processing Summary

10 min

Depending on the connectivity between customers, the error processing may differ slightly. This section lays out the error processing for the supported connection types. It also contains the error processing that happens within the Eligibility Request/Eligibility Response message that will be consistent regardless of connectivity type.

The system (Surescripts) will store the request until the receiver responds to the message or until the specified time has elapsed. If the timeout elapses before the message is processed, an error message will be returned to the sender as the reply (explained below). If the sender has timed out, the message is discarded.

The Eligibility Request/Eligibility Response are messages where Surescripts is a defined customer in the process and adds processing value in the middle. For that reason, additional error processing needs to be handled. The following section outlines the life of the Eligibility message with the expected responses to different flows of events. It is broken down into the following stages:

Surescripts receives the Eligibility Request from the requesting party.

Surescripts processes the Eligibility Request, identifying the coverage(s).

Surescripts passes the Eligibility Request to the defined source. (If multiple coverages are found, multiple Eligibility Requests are sent.)

The source processes the request(s) and returns an Eligibility Response.

Surescripts combines the response(s) into one envelope.

Surescripts passes the response back to the original requester.

Surescripts Receives the Eligibility Request from the Requesting Party (Provider Vendor)

Event Id	Location	Event	Surescripts Response	Error Description	Requestor Follow-Up
1.0	Connectivity Error	Cannot get response from Surescripts	None	None	Investigate and contact Surescripts representative
1.1	Translation	Surescripts cannot identify the message or does not have enough info to create a TA1	NAK	A Negative Acknowledgement (NAK) with a message that says: “TRANSACTION CANNOT BE IDENTIFIED NOR PROCESSED”	Investigate and contact Surescripts representative
1.2	Translation	Translator cannot identify the file (bad ISA or IEA segments) but can produce a TA1 response	TA1	Refer to X12 005010 Data Element Dictionary for acceptable codes	Investigate and contact Surescripts representative
1.3	Translation	EDI Format has Fatal errors -At any Level: Data Segment Data Element Transaction Set Functional Group	999	Refer to the 999 spec for a complete list of errors	Investigate and contact Surescripts representative

Surescripts Processes the Eligibility Request

Event Id	Location	Event	Surescripts Response	Error Description	Requestor Follow-up
2.0	Source Segment Loop ID – 2000A	Wrong platform Participant ID and/or password.	271	Loop ID 2000A AAA – Error 42 Unable to Respond a current time	C – Please correct and resubmit
2.1	Source Segment Loop ID – 2000A	Responder system goes down at any time in the process (Surescripts).	271	Loop ID 2000A AAA – Error 42 Unable to Respond a current time	P – Please resubmit
2.2	Source Segment Loop ID – 2000A	Requester puts bad data in the source segment. This should be Surescripts’ Participant ID.	271	Loop ID 2000A AAA – Error 79 Invalid participant identification	C – Please correct and resubmit
2.3	Source Segment Loop ID – 2000A	Requester is not set up to send eligibility message to Surescripts.	271	Loop ID 2000A AAA – Error 41 Authorization/Access Restrictions	N – Resubmission not allowed
2.4	Subscriber Name Segment Loop ID 2100C	Surescripts cannot find the desired patient	271	Subscriber Segment Loop ID 2100C AAA – Error 75 - Subscriber/Insured Not Found	N – Resubmission not allowed
2.4a	Subscriber Name Segment Loop ID 2100C	Surescripts cannot find the desired patient One of the demographic fields is missing	271	Subscriber Segment Loop ID 2100C AAA – Error 75 – Subscriber/Insured Not Found. Hint is in MSG segment.	C – Please correct and resubmit (Hint is sent back)
2.4b	Subscriber Request Validation Segment Loop ID 2110C	Version translation fails for outgoing 270	271	Subscriber Segment Loop ID 2110C AAA – Error 15 - Required application data missing MSG – Details of Error	C – Please correct and resubmit

Surescripts Attempts to Connect with Source (PBM/payer)

Event Id	Location	Event	PBM/payer Response	PBM/payer Error Description	Surescripts Follow up	Provider Vendor Error	Requestor Follow Up
3.0	Surescripts to PBM/payer Connector	Time Out – PBM/payer failed to reply to Surescripts in the specified time	None	None	Investigate and create AAA error for requestor	Source Segment Loop 2100A AAA – Error 80 No Response received - Transaction Terminated	P – Please Resubmit Original Transaction
3.1	PBM/payer Internal	Some failure at PBM/payer where they cannot produce a TA1 or 999	NAK	Text Error Message	Investigate and create AAA error for requestor	Source Segment Loop 2000A AAA – Error 42 Unable to respond at current time	S – Do not resubmit; Inquiry initiated to a third party.

PBM/payer Evaluates the Message

Event Id	Location	Event	PBM/payer Response	PBM/payer Error Description	Surescripts Follow up	Provider Vendor Error	Requestor Follow Up
4.0	Translation Initiation	Fatal Error with the ISA, GS	TA1	Refer to X12 005010 Data Element Dictionary for acceptable codes	Investigate and create AAA error for requestor	Source Segment Loop 2000A AAA – Error 42 Unable to respond at current time	S – Do not resubmit; Inquiry initiated to a third party.
4.1	Translation Initiation	EDI Format has Fatal errors -At any Level: Data Segment Data Element Transaction Set Functional Group	999	Refer to the 999 spec to determine AK level and appropriate error	Investigate and create AAA error for requestor	Source Segment Loop 2000A AAA – Error 42 Unable to respond at current time	S – Do not resubmit; Inquiry initiated to a third party.

PBM/payer Processes the Eligibility Request

Note: Errors that occur during any mapping/translation exercise would result in an AAA segment within the 2000A Source Segment. The error would be a 42 – Unable to respond at current time.

Generic Error messages for the following messages would result in a 42 within the segment where the error occurred.

Event Id	Location	Event	PBM/payer Response	PBM/payer Error Description	PBM/payer Follow up	Surescripts Follow up	Provider Vendor Error	Requestor Follow Up
5.0	Source Segment Loop ID 2100A (Note: Information Source is the PBM/payer info that was supplied by Surescripts)	Any issue that caused the process to halt during processing	271	Source Segment Loop 2100A AAA – Error 42 Unable to respond at current time	Investigate and contact Surescripts representative if additional information or clarification is needed.	None	Source Segment Loop 2100A AAA – Error 42 Unable to respond at current time	P – Please Resubmit Original Transaction
5.1	Source Segment Loop ID 2100A (Note: Information Source is the PBM/payer info that was supplied by Surescripts)	PBM/payer validates the Source Identifier to make sure it’s their own. Surescripts puts in wrong identifier	271	Source Segment Loop 2100A AAA – Error 79 Invalid participant Identification	Investigate and contact Surescripts representative	Investigate and translate to AAA system error for requestor	Source Segment Loop 2100A AAA – Error 79 Invalid participant Identification	S – Do not resubmit; Inquiry initiated to a third party
5.2	Source Name Segment Loop ID 2100A (Note: Information Source is the PBM/payer info that was supplied by Surescripts)	PBM/payer validates the source contact information. Surescripts puts in wrong PBM/payer contact name, etc.	271	Source Segment Loop 2100A AAA – Error 79 Invalid participant Identification	Investigate and contact Surescripts representative	Investigate and translate to AAA system error for requestor	Source Segment Loop 2100A AAA – Error 79 Invalid participant Identification	S – Do not resubmit; Inquiry initiated to a third party
5.3	Receiver Segment Loop ID 2100B (This loop contains the physician info and the provider vendor system info)	PBM/payer validates the receiver. PBM/payer wants more fields populated than what is required by Surescripts; i.e. – the POC is not identified.	271	Receiver Segment Loop ID 2100B AAA – Error 15 Required application data missing	None	None	Receiver Segment Loop ID 2100B AAA – Error 15 Required application data missing	C – Please correct and resubmit Surescripts recommends this value, however a PBM/Payer might send a different value
5.4	Receiver Segment Loop ID 2100B (This loop contains the physician info and the provider vendor system info)	PBM/payer validates receiver. PBM/payer cannot return eligibility for this patient because of the patients group or plan.	271	Receiver Segment Loop ID 2100B AAA – Error 41 – Authorization/ Access restrictions	None	None	Receiver Segment Loop ID 2100B AAA – Error 41 – Authorization/ Access restrictions	N – Resubmission not allowed Surescripts recommends this value, however a PBM/Payer might send a different value
5.5	Receiver Name Segment Loop ID – 2100B	PBM/payer validates the physician Identifier	271	Receiver Name Segment Loop ID – 2100B AAA – Error 43 Invalid/Missing Provider Identification	None	None	Receiver Name Segment Loop ID – 2100B Physician Loop AAA – Error 43 Invalid/Missing Provider Identification	C – Correct and Resubmit Surescripts recommends this value, however a PBM/Payer might send a different value
5.8	Subscriber Name Loop ID 2100C	Patient found at Surescripts, but not in the PBM/payer’s system (could be caused by a difference between Surescripts and the PBM/payer’s patient databases or caused by the patient demographic mismatch between requestor and PBM/payer).	271	AAA – Error 75 – Subscriber / Insured Not Found	None	None	AAA – Error 75 - Subscriber/Insured Not Found	S – Do not resubmit; Inquiry initiated to a third party

PBM/payer Sends Eligibility Response Back to Surescripts

Surescripts evaluates the message.

Event Id	Location	Event	Surescripts Response	Surescripts Error Description	PBM/payer Follow up	Surescripts Follow up	Provider Vendor Error	Requestor Follow Up
6.0	Translation of 271 from PBM/payer	Fatal Error with ISA or GS segments	TA1	Refer to Implementation Acknowledgment For Health Care Insurance (999)	Investigate and contact Surescripts representative	Investigate and translate to AAA system error for requestor	Source Segment Loop 2100A AAA – Error 42 Unable to respond at current time	S - Do not resubmit; Inquiry initiated to a third party
6.1	Translation of 271 from PBM/payer	EDI Format has Fatal errors -At any Level: Data Segment Data Element Transaction Set Functional Group	999	Refer to Implementation Acknowledgment For Health Care Insurance (999) to determine AK level and appropriate error	Investigate and contact Surescripts representative	Investigate and translate to AAA system error for requestor	Source Segment Loop 2100A AAA – Error 42 Unable to respond at current time	S - Do not resubmit; Inquiry initiated to a third party

Summary of Errors Sent to Provider Vendor

The following is a summary of some of the errors a provider vendor can expect to see.

Error	Description
Source Segment Loop ID - 2000A AAA – Error 42	Generic error message for all errors that occurred that were not caused by the provider vendor system.
Receiver Segment Loop ID - 2100B AAA – Error 15	If the provider vendor fails to give enough information in the message to identify themselves or the physician to the PBM/payer.
Source Segment Loop ID - 2000A AAA – Error 41	The sending customer is not set up to send an eligibility message.
Receiver Segment Loop ID - 2100B AAA – Error 41	If the PBM/payer determines that they cannot return information for this patient based off of the plan or group.
Receiver Segment Loop ID - 2100B AAA – Error 43	If the PBM/payer requires a DEA or state license number for the prescribing office but the provider vendor does not provide it.
Subscriber Name Segment Loop ID - 2100C AAA – Error 75	Surescripts cannot find the patient in the MPI.

Summary of Translated Errors

Segment	Error	Translation for Provider Vendor
Connectivity Type	All (Timeouts, NAKs, 999)	Source Segment Loop 2000A AAA – Error 42