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Back  RFI # 1440: CarveOut for Act/Inact ST 271

Formal vs. Informal Help Informal Formal

Submitter

Cory Everett

Description

We are looking for some direction based on how EB and associated segments for STs would displayed be on a 271 if a Carve-Out is coded. This is specific to carve-outs on active/inactive service types. Essentially, in the case when a carve-out is coded on an active/inactive service type, we could have two EB segments for the same ST. The specific scenarios we have questions on would be when the active/inactive service type is set to a status of U (EB01=U), and the associated carve-out would also have EB01=U.

Additionally, we could have an active/inactive status value where EB01= 1 or 6 or I, but the carve-out has EB01=U.

Either way, we are concerned that there could be some confusion with how the providers would interpret this on the 271. Can you recommend determine options we might have to suppress or respond with information to ensure it is not confusing to the providers?

Submitter Assigned Keywords

271, carve-out, active/inactive

Response

Additional requested information provided by the RFI submitter:

A group carves out their Vision coverage to an outside vendor so they would be sending an EB*U with the other entity info.

This same group though may cover a single vision exam under their wellness medical benefits, so we would need to return EB*1 to show the provider had some degree of medical coverage. This is a real world example we need to resolve for.

RESPONSE

When a benefit is Carved Out and handled by a third party, the correct way to identify the benefit coverage is by using EB01 = 1-5 and identifying the carve out plan information in the corresponding 2120 loop. See section 1.4.7.1 271 Item 8 for additional information on Carve Out.

When the determination of whether the individual is Active/Inactive is handled by another entity (such as the case with Labor Funds, see Section 1.4.7.1 271 item 11), EB01 = U (Contact Following Entity for Eligibility or Benefit Information) is used to indicate that coverage is completely handled by that entity. This should not be used to identify Carve Out benefits.

Recommendation

When overlapping benefits (such as vision exam covered by the Information Source but full vision benefits are carved out to a third party vision plan) use of EB05 for the plan product name (which would be the same as the one supplied in the EB loop that indicates Active/Inactive coverage for the plan) can aid in distinguishing the two plans. Even if there is no plan product name supplied in EB05, use of the 2120 loop will identify the carve out plan by name.

The example for the additional information provided by the RFI submitter would be:

EB*1**AN**Plan Name*23***VS*1~ (Active Coverage for Routine Vision Exam in the Plan Name for 1 visit per calendar year)
EB*1**AL**Carve Out Plan Name~ (Active Coverage for Vision [Optometry] in Carve Out Plan Name)
LS*2120~
NM1*2B*2*Carve Out Plan~ (Name of the Carve Out Plan company)
PER*IC**TE*8005551212~ (Contact phone number for the Carve Out Plan)
LE*2120~
Submission 10/25/2011
Status Date 1/13/2012
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Page19