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Back  RFI # 1358: 1.4.7.1 #8 Compliance Question

Formal vs. Informal Help Informal Formal

Submitter

karthik Subramanian

Description

ST30 prohibits payers from returning any of the listed 10 service types if the member is non-covered. The blues while being in compliance with the 5010 TR3, as part of its requirements, requires it's member Plans to return 6 additional service type codes (in addition to the HIPAA required 10 STC’s). While we do ask Plans to NOT return the HIPAA 5010 required codes when benefits are not covered, however we do require Plans return an EB01 = I (non-covered) for any of the BX required STC's for a 30 request. Of the 6 one of them is related to SPECIALIST and when the member is non-covered for SPECIALIST, Plans are required to return EB01 = I along with EB03 = 98, with the MSG ‘SPECIALIST’.

The 98 in this instance is utilized for an entirely different business purpose, and we do not believe we are out of compliance with the aforementioned section of the TR3.

Please confirm if you agree, and thank you for your time.

Submitter Assigned Keywords

A preliminary inquiry was made via email to Donna, Stuart and Amanda

Response

When responding to a Service Type Code (STC) 30 270 Inquiry, Section 1.4.7.1 item 8 expressly prohibits returning STC 98 as a non-covered benefit, regardless of if it is further qualified by a MSG segment.
Submission 7/15/2011
Status Date 1/4/2012
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1