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Back  RFI # 1588: 271 - EB12 on Deductible Lines

Formal vs. Informal Help Informal Formal

Submitter

Tucker David

Description

We need clarification on when we should us EB12=Y or N vs. EB12=W on our Deductible remaining line.

We have In Network IND deductible of $150 and Out of Network IND Deductible of $150.

The In Network deductible applies to In Network Providers only and the Out of Network deductible applies to Out of Network Providers only.

They each have $100 remaining to meet the Deductible.

It is our interpretation of the EB12 that since the network really does apply in this case, the In Network deductible only applies to In Network Providers and the Out of Network Deductible only applies to Out of Network Providers, then we must return the X12 as follows:


EB*C*IND*30***23*150*****Y
EB*C*IND*30***29*100*****Y
EB*C*IND*30***23*150*****N
EB*C*IND*30***29*100*****N

or should we return it as follows showing the remaining amount with EB12=W

EB*C*IND*30***23*150*****Y
EB*C*IND*30***23*150*****N
EB*C*IND*30***29*100*****W

Submitter Assigned Keywords

EB12 on Deductible Remaining Lines

Response

Additional information was requested from the submitter:

In your question you stated "We have In Network IND deductible of $150 and Out of Network IND Deductible of $150. " and "They each have $100 remaining to meet the Deductible. "

Please verify that the $150 and $100 represent deductible that must be met separately. In other words, if I were to satisfy the $150 in-network deductible (and in-network claims were starting to be paid) and then had out-of-network services, I would need to satisfy the out-of-network $150 deductible before any out-of-network claims would be paid.

Yes, this is correct.


Based on the additional information received from the submitter, the first example is correct.

EB*C*IND*30***23*150*****Y
EB*C*IND*30***29*100*****Y
EB*C*IND*30***23*150*****N
EB*C*IND*30***29*100*****N

When the deductible (or any benefit for that matter) is handled differently when it is in-network than it is for out of network (regardless of whether or not the values are coincidentally equal), it is correct to create separate 2110 loops for in-network and out of network benefits with the use of EB12 to indicate whether it is for in-network or out of network.

When the deductible (or any benefit for that matter) is considered one benefit when it is in-network or out of network, it is correct to create a single 2110 loop for in-network and out of network benefits with the use of EB12 = W to indicate that the benefits are the same regardless of whether they are in-network or out of network.
Submission 5/8/2012
Status Date 6/29/2012
Status F - Final
Primary References
Document 005010X279
Section2.6
Industry NameYes/No Condition or Response Code
Code ValueW