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Back  RFI # 1424: 5010 271 EB11 Pre-Cert

Formal vs. Informal Help Informal Formal

Submitter

Cory Everett

Description

For a pre-certification (EB11) and assoc MSG seg and LS/LE loop w/ NM1 and PER segs, is there any guidance on which EB01 value the authorizations should be assigned to? The auth may apply to all benefits for the same service type or it could be partial. The structure of the 271 is confusing for providers because the authorizing entity is only tied to one benefit on the 271 even if it applies to all EBs for the same service type. Here is an example for my questions:
EB*A**2*****.3***U*N~
MSG*APPLIES TO ABC PROCS~
LS*2120~
NM1*X3*2*MEDICAL MANAGEMENT~
PER*IC**TE*8665555555~
NM1*X3*2*PRE-CERT GROUP~
PER*IC*PROV SERVICES*TE*8885555555~
LE*2120~
#1 - Is there any guidance on an EB01 value to include the authorizing entity on? Can an EB01 value be defined in a future release for Pre-Certification?
#2 - is there any guidance for how to better use the structure when we need to include mult authorizing entities, the MSG segments for each, and then potentially a MSG segment related to the benefit?

Submitter Assigned Keywords

271 EB11 Authoization

Response

#1. If a service requires authorization the guide does not require inclusion of the Authorization entity with any specific EB01 valued 2110 loop. The work group will discuss identifying a specific value for EB01 to assist in identifying the Authorizing entity for potential inclusion in a future version of the implementation guide. See the recommend section below.

#2. The example given identifies two entities that are to be contacted for authorizations and it appears that they have been lumped together under a group of procedure codes which can be accomplished by using the procedure code range function of EB13. The guide requires use of codified solutions rather than MSG segments. The appropriate response would be to identify each entity in separate 2110 loops, using the procedure code range function of EB13 for the procedure codes that applies to each entity. The response should be tailored to the 270 inquiry rather than returning all scenarios that apply at a high level. Use of the MSG segments should be used sparingly and only if their content cannot be codified.

Recommendation

While it is not required, you may wish to consider including the Authorization entity with the EB loop that identifies the benefit as Active coverage (EB01 = 1-5) rather than including it with the financial information.

While there is no requirement to prevent sending multiple iterations of NM101 values within the same 2120 loop, this will likely cause data collision where more than one entity is identified for the same purpose or at a minimum confusion to the provider. The intent was to return only one iteration (the NM1 is allowed to repeat 23 times in 2120 and there are 23 distinct NM101 codes).
Submission 10/3/2011
Status Date 1/5/2012
Status F - Final
Primary References
Document 005010X279
Section271 EB
Page291
Loop2110
Secondary References
RFI ID 1872
Document 005010X279
Section271 LSLE
Loop2120