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Back  RFI # 1363: Eligibility/benefit interpret

Formal vs. Informal Help Informal Formal

Submitter

Kim Peters

Description

How can the following scenarios be reported in a 5010 271? We can't determine the proper reporting approach.

1 - Tiered Copayment Example:
An office visit with in network Doctor A has a $0 copayment.
vs
An office visit with in network Doctor B has a $50 copayment.

(essentially multiple levels of copayment depending on which “in network” doctor is seen)

2 - A plan takes 150.00 copay per day for first three days per admission then 100.00 copay per day per admission from that point forward.

Submitter Assigned Keywords

benefit interpret

Response

1 - The tiered benefits can be done with one 2110 loop for the in network $0 copay with a 2120 loop to identify Doctor A and a separate 2110 loop for the in network $50 copay with a 2120 loop to identify Doctor B.

2 - The second scenario would have to use a combination of EB segments and HSD segments. The first copay would be one 2110 EB01 = B (Co-payment) with EB06 = 36 (Admission) and the amount in EB07 (150) and either a service type code in EB03 or a procedure code in EB13 and an HSD segment with HSD03 = DA (Days), HSD04 = 1, HSD05 = 31 (Not Exceeded) and HSD06 = 3 (identifying the "per day not exceeded 3"). The second copay would be another 2110 EB01 = B (Co-payment) with EB06 = 36 (Admission) and the amount in EB07 (100) and either a service type code in EB03 or a procedure code in EB13 and an HSD segment with HSD03 = DA (Days), HSD04 = 1, HSD05 = 30 (Exceeded) and HSD06 = 3 (identifying the "per day exceeded 3").
Submission 7/21/2011
Status Date 12/6/2011
Status F - Final
Primary References
Document 005010x279
Section271 2110