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Back  RFI # 1473: Tier Benefit - Visit Maximums

Formal vs. Informal Help Informal Formal

Submitter

Tucker David

Description

Below is an example of a benefit that I am trying to codify using X12 values without the MSG TXT following (RIF 719).
I am having issues codifying this type of benefit because I cannot find where I should put the PER CALENDAR YEAR time period qualifier for this benefit.
Will you please review and provide any guidance on how this type of benefit can be completely codified using X12 values or is this a benefit that cannot be completely codified at this time and use of MSG TXT is acceptable.

Service Type 33 Chiropractic (In Network and Out of Network) with the following schedule:

* Copayment = $10.00 per visit for visits 1-10 per calendar year
* Copayment = $20.00 per visit for visits 11-30 per calendar year
* Copayment = $30.00 per visit for visits over 30 per calendar year

Here is an example of my coding

EB*B*IND*33***27*10*****W~HSD***VS**31*10
EB*B*IND*33***27*10*****W~HSD***VS**30*10~HSD***VS**31*30~
EB*B*IND*33***27*10*****W~HSD***VS**30*30

Submitter Assigned Keywords

Tier Benefit - Visit Maximums

Response

The calendar year can be identified using the 2110C/D DTP segment with DTP01 = 292 (Benefit) and the dates in DTP03.

Based on the example above, the correct response would be:

EB*B*IND*33***27*10*****W~
HSD***VS**31*10~
DTP*292*RD8*01012012-12312012~
EB*B*IND*33***27*20*****W~
HSD***VS**30*10~
HSD***VS**31*30~
DTP*292*RD8*01012012-12312012~
EB*B*IND*33***27*30*****W~
HSD***VS**30*30~
DTP*292*RD8*01012012-12312012~

The copayment amounts in the second and third EB segments have been corrected to correspond to the text identified.
Submission 12/15/2011
Status Date 3/6/2012
Status F - Final
Primary References
Document 005010X279
Section1.4.12
Page37