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Back  RFI # 1605: EB12=W Remaing Amount Zero

Formal vs. Informal Help Informal Formal

Submitter

Tucker David

Description

We have In Network IND deductible of $150 and Out of Network IND Deductible of $300.

The In Network and Out of Network deductible apply to each other. Any deductible for an In Network Provider reduces the deductible remaining amount for both the In Network Deductible and the Out of Network Deductible and vice versa, any deductible for an Out of Network Provider reduces the deductible remaining amount for both the In Network Deductible and the Out of Network Deductible.

They each have $0 remaining to meet the Deductible.

In this scenario should we return the remaining dollars of zero with the EB12 Y and N


EB*C*IND*30***23*150*****Y
EB*C*IND*30***29*0*****Y
EB*C*IND*30***23*300*****N
EB*C*IND*30***29*0*****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*300*****N
EB*C*IND*30***29*0*****W

Submitter Assigned Keywords

EB12=W

Response

The first example is correct as you would be indicating both in and out of network deductibles have been met.

EB*C*IND*30***23*150*****Y
EB*C*IND*30***29*0*****Y
EB*C*IND*30***23*300*****N
EB*C*IND*30***29*0*****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. Since the out of network deductible is a higher amount than the in network deductible, and even though the deductible collected for in network applies to the out of network deductible, the out of network deductible may not be completely satisfied when the in network deductible has been satisfied. Even when both in and out of network deductibles have been satisfied, since they were not a common deductible, it is correct to report them separately. Combining the deductibles once they have both been satisfied could create confusion for the receiver of the transaction.
Submission 6/13/2012
Status Date 8/7/2012
Status F - Final
Primary References
Document 005010X279
Section2.6
Industry NameYes/No Condition or Response Code
Code ValueW