RFI Browser

Back  RFI # 1463: age tiered benefits

Formal vs. Informal Help Informal Formal

Submitter

James Sherwood

Description

Our question is how do we return the benefit below using X12 values (for age tiered benefits) or is it more appropriate to use MSG TXT for the date ranges in these scenarios.

Case 1

Service Type BH - Pediatric

Co-insurance is 10% for ages 1-2
Co-insurance is 15% for ages 3 -4
Co-insurance is 20% for ages 5 – 6

Submitter Assigned Keywords

age tiered benefits

Response

Section 1.4.12 Message Segments explicitly prohibits use of the MSG segment to relay this type of information since it can be codified.

Section 1.4.7.3 discusses streamlining the 271 response to fit the person whose benefits are being returned. Section 1.4.7.4 specifically notes returning only benefits “matching the age of the patient should be sent”.

The 271 response is to relay the benefits in effect for the patient based on the date(s) from the 270 inquiry. If no date is sent in the 270, the transaction is to respond with the benefits in effect on the date the transaction is processed. Since the patient’s date of birth would be known to the creator of the 271 response, the benefits (in this case the co-insurance) applicable to the patient can also be identified.

As an example, using a patient date of birth of January 1, 2009 for an inquiry dated December 5, 2011 the following co-insurance would be returned.

EB*A**BH*****.1~

NOTE: If the plan date was not returned in 2100C/D as outlined in section 1.4.7.1 item 1, the applicable date for the co-insurance for the date of the request would be returned as DTP*292*D8*20111205~ following the EB segment.

In the event that the 270 request dates spanned more than one benefit period such as December 5, 2011 to January 5, 2012, the following co-insurance would be returned:

EB*A**BH*****.1~
DTP*292*RD8*20111205-20111231~
EB*A**BH*****.15~
DTP*292*RD8*20120101-20120105~

Alternatively, the beginning and end dates for each of the applicable periods could also be returned. For example:

EB*A**BH*****.1~
DTP*292*RD8*20090101-20111231~
EB*A**BH*****.15~
DTP*292*RD8*20120101-20131231~

Recommendation

As noted above, sections 1.4.7.3 and 1.4.7.4 (as well as section 1.4.7.5) encourage the streamlining of the 271 response to match the patient. Providers do not need to know the entire set of benefits for every member of the plan; they want to know what applies to their patient for the date(s) they ask about.

Providers routinely complain about receiving irrelevant information and will typically pick up the phone and call rather than sift through the irrelevant information to find the benefits that actually apply to the patient.
Submission 12/5/2011
Status Date 1/13/2012
Status F - Final
Primary References
Document 005010X279
SectionEB