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Back  RFI # 1281: 271 Pre-existing Condition

Formal vs. Informal Help Informal Formal

Submitter

Gladys Jones

Description

The 270 does not allow a request for pre-existing conditions. When is the 271 required to return “M” (pre-existing condition)? Is other information required to be returned other than "M"?

We are unclear how/when to use the pre-existing code-value in the 271 response.

Submitter Assigned Keywords

pre-existing condition

Response

The requirements for a 271 response are outlined in 1.4.7.1. There is no requirement to return pre-existing condition information. If the information source uses the value M in EB01, the pre-existing qualifier “M” in EB01 can be used stand-alone or with other information the information source determines is necessary.

Often and most common, the Pre-existing Condition qualifier will be used in conjunction with the EB03 value of W, and a DTP identifying the date the wait period is complete, where DTP01 = 198 (Completion).

Recommendation

It is recommended that the information source identify any additional information that will help guide the provider in their service or treatment of the member. The example above shows one scenario where it is highly recommended the information source return on the 271 response where and when applicable.
Submission 3/23/2011
Status Date 7/22/2011
Status F - Final
Primary References
Document 005010X279
Section1.3.4
Page220
Set ID271
Table2
Loop2110C
Segment Position130
Segment IDEB
Element PositionEB
Industry NameEligibility or Benefit Information
Code ValueM