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Formal vs. Informal Help Informal Formal


Stacey Barber


How is patient financial responsibility returned when there is a base responsibility at the plan level, but there are some benefits for which it does not apply?A member is covered by a plan with 10% co-insurance. All but 1 of the required service types are covered. Seems the response would be
If there are 3 services not covered, 1 is capitated, 1 is a carve-out to a secondary plan, & 1 is simply not covered, it is less clear if the co-insur should be presented at the plan level. There appear to be 2 approaches. The 1st includes the co-insurance at the plan level and the 2nd includes it at the service type level for those services that are directly covered. Which of these approaches is correct format, if both are acceptable, or if one is preferred?
Approach 1
Approach 2

Submitter Assigned Keywords



Section 271 item 8 states that for responses to a 270 EQ01 = 30 request, for the listed codes 1, 33, 35, 47, 86, 88, 98, AL, MH and UC “The above codes must have the appropriate EB01 = 1-5. If it is not a covered benefit, the code must not be returned.” The three examples above each identify EB03 service type code 88 (Pharmacy) with an EB01 of I – Non-Covered, which is not compliant with the requirements of the 005010X279 TR3. This service type code must not be returned for a 270 inquiry of 30.

The service type codes required by section 271 Item 8 are high level benefit categories, but are not intended to represent all benefits covered by a plan so it would be more appropriate to report plan level patient financial responsibility at the plan level. If some of the benefits have patient financial responsibility that differs from those of the overall plan, it is appropriate to indicate those differences at the service type level.

For the service type code that is capitated, it is appropriate to have a separate EB segment indicating that the service type is capitated. This indicates that the service type code that is capitated is not subject to the plan level co-insurance.

For the benefit that is carved out, EB01 = W (Other Source of Data) is not compliant with the requirements of the 005010X279 TR3. Section 271 Item 8 states “The above codes must have the appropriate EB01 = 1-5. If it is not a covered benefit, the code must not be returned. The repetition function of EB03 must be used if only reporting the Active Status or if Patient Responsibility is the same across multiple benefits. If any of the above benefits are associated with another entity (e.g. carve out) the information must be returned in 2120C/D if known.” To be compliant with these requirements, indicate Active Coverage (EB01 = 1-5) and identify the carve out entity in the 2120 loop.

Using your example (assuming Mental Health (MH) is carve out, Pharmacy (88) is not covered and Dental (35) is capitated):

EB*1**1^33^47^86^98^30^ AL^UC ~


General comments about the examples included in the request:

Co-insurance values are returned in EB08, all of the examples included in the request incorrectly place the value in EB06.

The Approach 2 example appears to have reversed the EB01 values in the first two EBs.

It is also presumed that the examples included in the request are only a portion of the response as there are a number of required items missing for a response that would be compliant with the requirements of the 005010X279.
Submission 3/26/2012
Status Date 8/10/2012
Status F - Final
Primary References
Document 005010X279
Section271 Resp