45 C.F.R. Subpart L—Eligibility for a Health Plan
Title 45 - Public Welfare
The eligibility for a health plan transaction is the transmission of either of the following: (a) An inquiry from a health care provider to a health plan, or from one health plan to another health plan, to obtain any of the following information about a benefit plan for an enrollee: (1) Eligibility to receive health care under the health plan. (2) Coverage of health care under the health plan. (3) Benefits associated with the benefit plan. (b) A response from a health plan to a health care provider's (or another health plan's) inquiry described in paragraph (a) of this section. The Secretary adopts the following standards for the eligibility for a health plan transaction: (a) For the period from October 16, 2002 through October 15, 2003: (1) Retail pharmacy drugs. The National Council for Prescription Drug Programs Telecommunications Standards Implementation Guide, Version 5, Release 1, September 1999, and equivalent NCPDP Batch Standards Batch Implementation Guide, Version 1, Release 0, February 1, 1996. (Incorporated by reference in §162.920). (2) Dental, professional, and institutional health care eligibility benefit inquiry and response. The ASC X12N 270/271—Health Care Eligibility Benefit Inquiry and Response, Version 4010, May 2000, Washington Publishing Company,004010X092. (Incorporated by reference in §162.920). (b) For the period on and after October 16, 2003: (1) Retail pharmacy drugs. The National Council for Prescription Drug Programs Telecommunication Standard Implementation Guide, Version 5, Release 1 (Version 5.1), September 1999, and equivalent NCPDP Batch Standard Batch Implementation Guide, Version 1, Release 1 (Version 1.1), January 2000 supporting Telecommunications Standard Implementation Guide, Version 5, Release 1 (Version 5.1) for the NCPDP Data Record in the Detail Data Record. (Incorporated by reference in §162.920). (2) Dental, professional, and institutional health care eligibility benefit inquiry and response. The ASC X12N 270/271—Health Care Eligibility Benefit Inquiry and Response, Version 4010, May 2000, Washington Publishing Company, 004010X092 and Addenda to Health Care Eligibility Benefit Inquiry and Response, Version 4010, October 2002, Washington Publishing Company, 004010X092A1. (Incorporated by reference in §162.920). [68 FR 8398, Feb. 20, 2003; 68 FR 11445, Mar. 10, 2003]
Title 45: Public Welfare
PART 162—ADMINISTRATIVE REQUIREMENTS
Subpart L—Eligibility for a Health Plan
§ 162.1201 Eligibility for a health plan transaction.
§ 162.1202 Standards for eligibility for a health plan transaction.
