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Back  RFI # 1100: 1.4.7.1 Item 8 and 9

Formal vs. Informal Help Informal Formal

Submitter

Boyle-Campbell Donna

Description

As a payer, we often have complex, convoluted benefit packages offered to our accounts. As such, it becomes difficult processing E&B inquiries and delivering a valuable message. As a result, we have "blocked" all benefits for particular accounts no matter which the provider is doing the inquiry. We return the 271 with a phone number to call our customer service for the benefit information needed.

With the requirements outlined in 1.4.7.1, specifically, items 8 and 9, it's my understanding we can no longer "block" benefits, rather, we have to minimally return what's required in item 8 or 9, depending on the inquiry service type code.
Is this understanding correct? That is, we must return the service types outlined in item 8 or 9 in the least, depending on the service type code submitted in the 270 EQ, and cannot block ALL benefits?

Response

This issue is explicitly addressed in guide 005010X279.
Section 1.8 states "A trading partner agreement must not override the specifications in this implementation guide if a transmission is reported in GS08 to be a product of this implementation guide."

Section 1.4.7.1 states "If the individual is located in the information source's system, the following must be returned:". Items 8 and 9 referenced above follow that statement in the same section.

Therefore, blocking or any other action that fails to provide the required information when an individual is located in the information source's system is not permitted in a transaction compliant with this guide. Your understanding is correct. In addition to not being able to block ALL benefits, the guide requires that you not block ANY of the benefits in the minimum requirement list in section 1.4.7.1.

Recommendation

If the need exists to convey contact information for the information source to allow the provider to call for information at the benefit level, it must be returned in the 2120 C/D NM1 and PER segments.
Submission 7/8/2010
Status Date 7/30/2010
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Page20
Set ID270271