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Back  RFI # 1628: 271 - Benefits Sub-types

Formal vs. Informal Help Informal Formal

Submitter

SAM HERBERT

Description

For the 271 response, if the benefits for a service type in our core health care software are represented by sub-types -- i.e. if the benefits cannot be described at the level of the service type, how can we best respond on the 271?

Example: our 271 copays for a 'Pediatric' benefit would be different, depending on whether it is an office visit, well-child visit, or an immunization. How should we respond in this case? We do not see on the 271 structure where we can respond with certain benefit "sub-service" benefit types.

Submitter Assigned Keywords

270-271 transaction sub-service benefit types

Response

The 005010X279/005010X279A1 TR3 can address sub service benefit types in a variety of ways, such as when they are age based benefits.

The 005010X279/005010X279A1 TR3 can accomplish identifying service type codes for the example in the request (“copays for a 'Pediatric' benefit would be different, depending on whether it is an office visit, well-child visit, or an immunization”) by using the EB09 code value S7 - Age, High Value and related upper age limit for the pediatric sub service benefit type in EB10 within the 2110 EB segment.

EB*B**98***27*10**S7*18~
EB*B**BZ***27*15**S7*18~
EB*B**80***27*20**S7*18~

Recommendation

Although the description did not ask how to convey non-Pediatric benefits, the following information is an example of Geriatric sub service benefit types.

To return "Geriatric" benefits, the EB09 value S8 - Age, Low Value would be used with the lowest age threshold in EB10 within the 2110 EB segment.

EB*B**AG***27*50**S8*65~
EB*B**44***27*25**S8*65~

Also, see RFI 1463 for additional age related benefit examples.
Submission 7/17/2012
Status Date 10/30/2012
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Page397
Set ID271
Segment Position03
Segment IDEB
Industry NameService Type Code