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Back  RFI # 1657: Codify a tiered benefit

Formal vs. Informal Help Informal Formal

Submitter

Denise Bower

Description


We have a tiered benefit that is for the following;
In-Network coinsurance applied as follows:
- 20% for the first $10,000 of allowed expenses
- 10% for the next $20,000 of allowed expenses
- 5% for the next $20,000 of allowed expenses
- No coinsurance when $50,000 of allowed expenses has been reached

Previously, we used EB01-A to build this. However with 5010 we cannot use EB07 amounts with EB01=A. I am trying to figure how to codify this. I submitted a helpdesk ticket asking the same thing and was told this information cannot be codified. It has to be identified (tiers) in MSG segments.

I wanted to hear your thoughts on how this information can be codified.

Response

For each tier of co-insurance you would use a 2110 EB segment with EB01 = A (Co-Insurance) and the co-insurance percent value in EB08 and identify the dollar amount information in the corresponding 2110 MSG segment.

For the last tier where no co-insurance applies, you could alternately use a 2110 EB segment with EB01 = G (Out of Pocket – Stop Loss) and place 50000 in EB07, if indeed there are no addition out of pocket expenses. In this case there would be no need to identify the 0 Percent Co-insurance.
Submission 8/6/2012
Status Date 10/22/2012
Status F - Final
Primary References
Document 005010X279
Section2.6
Page289
Set ID271
Loop2110
Segment PositionC
Segment IDEB
Element Position
External Code List22
Code ValueX12