RFI Browser

Back  RFI # 1618: 271 2110C/D EB05 Plan Name

Formal vs. Informal Help Informal Formal

Submitter

Cindy Monarch

Description

In Section 1.4.7.1, item 2, as well as in the situational rule for 2110C/D EB05 data element, reporting of the Plan Name is required when the Plan Name “exists” and EB01 status = 1, 2, 3, 4, 5, 6, 7 or 8 and EB03 Service Type Code = 30. Eligibility and benefit inquiries for our dental product is currently handled by a separate TPA. Our dental group benefits do have affiliated plan names; however, this information is not provided to our dental TPA. Consequently, the plan name does not exist within their system and they are not able to report this information in the EB05 data element. We would appreciate clarification regarding the term “exists” as applied in this situational rule. Is it based on what is available within the system of the entity responding to the eligibility and benefit inquiry?

Submitter Assigned Keywords

Clarify EB05 Plan Name exists

Response

There are two sections in the 005010X279 TR3 that relate to this request. The first Section 1.4.7.1 271 item 8 with regards to Dental Benefits. When a patient has Dental benefits (or any of the other benefits listed in item 8) that are handled by another entity, the guide states “If any of the above benefits are associated with an other entity (e.g. carve out) the information must be returned in 2120C/D if known.”

In your response, an example of how this would be relayed is as follows:

EB*1**35~
LS*2120~
NM1*2B*2*DENTAL TPA NAME HERE~
N3*STREET ADDRESS~
N4*CITY*ST*ZIP~
PER*IC*TPA CUSTOMER SERVICE*TE*8005551212~
LE*2120~

A provider who is seeking dental benefits would then submit a 270 request to the Dental TPA.

The second section related to this request is Section 1.4.7.1 271 item 2. This section applies to the plan the member belongs to for the information source identified in loop 2100A. For the information source who initially received the request, only the plan name associated with the benefits administered by them would be returned in EB05 of the EB segment with EB*1**30. In the case of the dental TPA, when they receive a 270 request, they would be required to return the dental plan name in EB05 of the EB segment with EB*1**30.

As to whether an information source must return a plan name if one exists, if a name has been assigned to a plan, it exists. In order to be compliant with the requirements of the 005010X279 TR3, if a name has been assigned to a plan and therefore exists, it must be returned in EB05 as indicated in Section 1.4.7.1 271 item 2 and the 2110C/D EB05 Situational Rule as noted in the description for any plan the patient is a member of and administered by the information source.

The requirement does not state to return the plan name if the plan name exists within the system of the entity responding to the eligibility and benefit inquiry. When a plan name has been assigned for the plan the member has active or inactive coverage in, failure to provide a plan name to the responding system does not exempt an entity from complying with the requirement to return the plan name.

Recommendation

In order for the TPA to return a 271 that complies with Section 1.4.7.1, item 2, as well as in the situational rule for 2110C/D EB05, the Information Source must provide the TPA with the applicable plan name if one exists within its system unless the TPA assigns its own plan name.
Submission 7/3/2012
Status Date 9/27/2012
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Page20
Set ID271
Table2
Loop2110C
Segment Position1300
Segment IDEB
Element Position05