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Back  RFI # 1557: 1.4.7.1 271 requirements- DTP

Formal vs. Informal Help Informal Formal

Submitter

Maureen Yearwood

Description

This issue is related to pg 19 of the 270/271 imp guide, item 1 under 1.4.7.1.

We are getting a response from a Medicaid payer that 1- doesn't have the required 346 and 2- when using the alternate 291 qualifier only the current date is returned. If a date range is sent the range is mirrored in the 271 with the 291 qualifier. Providers are contending that 1- a 346 should be returned or 2- the alternate 291 should not be a "current" date or the exact date range inquired on but rather the true benefit plan dates. Payer states- This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s), so they return current date.
Please let me know if additional information is needed.

Response

Section 1.4.7.1 271 item 1 contains the following:

“If the individual has active coverage, the 346 Plan Begin date must be returned in 2100C/D DTP unless multiple plans apply to the individual or multiple plan periods apply, which must then be returned in the 2110C/D DTP. May alternately return a 291 Plan range of dates if known.”

Section 1.4.7.1 271 item 1 also contains the following note that clarifies what the Plan Begin or Plan Range of Dates are to represent:

“NOTE: Plan dates represent coverage dates in the plan or program that is being represented in the response. This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s). For example, Medicaid may only report plan dates in one month periods of time.”

The use of the current date or the dates from the inquiry are not compliant with the requirements of the 005010X279 TR3 unless they coincidentally are the actual begin or range of coverage dates. Typical Medicaid plan dates would be in one month increments with the plan begin date being the first day of the month reported, unless the plan reports historical coverage of more than one month. Most Medicaid plan end dates would also likely be the end of the month. There may be exceptions to this general understanding such as for retroactive activation or termination of coverage.

While there are no explicit examples provided, if a health plan is merely echoing the dates from the 270 request and not identifying the actual Plan Begin Date as outlined above, that health plan would be out of compliance with the requirements of the 005010X279 TR3. While this was acceptable for minimum compliance with 004010X092, it is no longer the case for compliance with 005010X279.
Submission 4/3/2012
Status Date 5/24/2012
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Page19
Segment IDDTP