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Back  RFI # 1727: X12 271 EB Segment & Copayment

Formal vs. Informal Help Informal Formal

Submitter

David Merwitz

Description

I am currently working with a client (health plan) that offers a benefit package that includes DME with a patient responsibility that is a co-payment based on a percentage of the retail/wholesale cost of the item from the provider. In reviewing the TR3 for the X12 271 transaction it specifically states that if Element EB01 is set to “B” (Co-payment) that a corresponding dollar amount must be used in element EB07 indicating the co-payment amount. However, in the benefit design described above, the health plan would like to use element EB08 which is a percentage rather than the EB07 element prescribed in the TR3. Is there any prohibition in doing so? Will this create a syntax error or other issue? Or is this something that trading partners simply need to be made aware of so that when received they know that an EB08 may accompany a “B” in EB01?

Submitter Assigned Keywords

Co-payment

Response

Section 1.4.9 of the guide states "For each of the EB01 code values that represent either a dollar amount or a percentage based upon patient responsibility, codes and their definitions have been identified and instructions on how to use them in conjunction with this Implementation Guide are included below." Definitions for both co-insurance and co-payment then follow. The situation described matches the definition for co-insurance, not co-payment.

The situational rule for EB08 states "Required when EB01=A. Do not use if EB01=B, C, G, J or Y. May be used at the sender's discretion for other EB01 values."

Therefore, even though the health plan calls this benefit a co-payment, for the purposes of the 271 transaction this is a co-insurance and must be reported that way (EB01 code "A"), with the percentage reported in EB08, and not as co-payment (EB01 code "B"). EB01 code "B" cannot be used with a percentage in the EB08 element.
Submission 1/2/2013
Status Date 2/19/2013
Status F - Final
Primary References
Document 005010X279
Section1.4.9
Page33
Set ID271
Loop2110C
Segment IDEB
Industry NameEligibility or Benefit Information Code
Code ValueB