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Back  RFI # 1143: 1.4.7.1 Individual is located

Formal vs. Informal Help Informal Formal

Submitter

Boyle-Campbell Donna

Description

Based on contract arrangements with labor funds, we return 271 responses with either (1) eligibility (and a phone number for benefits), (2) eligibility & benefits, or (3) no eligibility or benefits, rather, a labor fund phone number for eligibility & benefits. The first option above is because we only have the eligibility in our system and the benefits are maintained by the labor fund.
With the requirements outlined in 1.4.7.1, specifically, items 8 and 9, it's my understanding we can no longer return eligibility only if the member is found in the information sources' system, that those coverages/benefits in item 8/9 must also be returned.
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 (outlined in item 8/9), and cannot return ONLY eligibility? (Of course, this question can also extend to the EQ 60 STC and the requirements of 1.4.7.1)
Can we use item 11 as a way to do elig only?

Submitter Assigned Keywords

Located Individual

Response

Your understanding of the requirements of section 1.4.7.1 271 item 11 is not entirely accurate.

Section 1.4.7.1 271 Item 11 allows an information source to identify the true source of information (such as labor funds). Item 11 does not require identifying the Active or Inactive status, but if that information is available you are not prohibited from returning Active or Inactive status in a 2110 EB segment. If the benefit details are maintained by the true information source, identify that source with a second 2110 loop with EB01 = U.

Recommendation

While Section 1.4.7.1 271 Item 11 does not require returning any of the information outlined in items 1 through 9, however, it is highly recommended that all of the available information identified in items 1 through 9 be returned.
Submission 8/26/2010
Status Date 11/19/2010
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Page19
Set ID270271
Secondary References
RFI ID 1051
Document 005010X279
Section1.4.7.1
Page21
Set ID270271