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Back  RFI # 1653: Explicit Service Type Status

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Submitter

Deb McCachern

Description

Section 1.4.7.1 of the 005010X279 TR3 states in item # 9 that if a health plan receives an explicit request for service types 1, 33, 35, 86, 98, AL, MH, or UC, they are required to return the items identified in items 1-6. Item 2 states that an EB01 of 1-8 must be returned with EB03=30. I interpret this to mean that the active/inactive status must be reported at the plan level.

Is it acceptable to report benefits (such as financials) only for the explicit service type and not the status for that service type? For example, in response to a request for service type 98, is the following acceptable?

EB*1**30*ABC PLAN~
EB*B**98****10**VS*1~

Or does it need to be like this:

EB*1**30*ABC PLAN~
EB*1**98~
EB*B**98****10**VS*1~

Submitter Assigned Keywords

explicit service types EB

Response

The intent of 005010X279A1 Section 1.4.7.1 271 item #9 is to identify what is required to be returned in addition to the status of coverage for the explicit service type code received in the 270. Items 1 through 6 from section 1.4.71 are to be returned in addition to the Active status (EB01 = 1 through 5) or that it is not a covered benefit (EB01 = I) for the service type code if it is a supported service type request when received by the information source.

The second example from the request would be the compliant response.

EB*1**30*ABC PLAN~
EB*1**98~
EB*B**98****10**VS*1~
Submission 8/3/2012
Status Date 10/2/2012
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Set ID271
LoopEB