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Back  RFI # 1621: 271 -- Diagnosis Based Benefit

Formal vs. Informal Help Informal Formal

Submitter

Millard Wayne

Description

We represent a few plans that have diagnostic based benefits. For example, the Office Visit service type would have different copayments depending on the reason the person is seeking service. Well Care pays with one copayment, Diabetes with another, TMJ with another, Maternity with another, Weight Loss with another, Infertility with another, etc.

We have two issues with codifying this information:

#1) Many of the 'treatment reasons' encompass a range of diagnosis codes. The HI segment is only setup for a single diagnosis per each of the 8 slots.

#2) Some of the plans have more than 8 different treatment reasons and currently the HI segment is setup on the 271 to only allow for 8 diagnosis codes.

We also have not been able to limit based on the provider as some provider specialties (like a family doctor) can treat virtually anyting.

Would this be an allowable use of the Message Segment (i.e. "This Benefit Information Applies to Treatment of Diabetes Only", etc.)?

Submitter Assigned Keywords

271 treatment reason diagnosis MSG

Response

The example given in the description would result in a hybrid response containing a mix of diagnosis codes and MSG segments.

The 005010X279/005010X279A1 TR3 Section 1.4.12 Message Segments state “Under no circumstances can an information source use the MSG segment to relay information that can be sent using codified information in existing data elements (including combinations of multiple data elements and segments).” This requirement still applies, however, due to the limitation in 005010X279/005010X279A1 of the HI segment only allowing 8 diagnosis codes, the need to represent more than 8 diagnosis codes lends itself to using the MSG.

It would be compliant with the requirements of the TR3 to return the first 8 individual diagnosis codes in the 271 2100C/D loop HI segment, using EB14 to point back to the related diagnosis in the HI.

If there is a need for more than 8 diagnosis codes, usage of the MSG segment for the additional diagnosis codes that could not be codified would be compliant.

Recommendation

Since these co-payment amounts are specific to diagnosis codes, it is recommended that you support these types of inquiries in the 270 in order to return very specific benefit related co-payments. Sending back a litany of co-payments for a more general response would not be recommended.
Submission 7/10/2012
Status Date 10/30/2012
Status F - Final
Primary References
Document 005010X279
Section1.4.12
Set ID271