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Back  RFI # 1737: Dup Remaining Seg EB03 Repetng

Formal vs. Informal Help Informal Formal

Submitter

Paul Wanderscheid

Description

Subscriber/Dependent has two benefit accumulations for Diabetic Ed. Both are coded with an EB03=03 and all other EB segments are exactly the same with the exception of the MSG segment:
Diabetic Education Follow-up Visit Limit - 2 lifetime visits
Diabetic Education Program Visit Limit - 2 lifetime visits

Using EB03 Repeating Functionality, how would we return the remaining amounts since both benefit accumulations have the same number of visits remaining (2) and all other EB segments are identical?
If we are using EB03 Repeating Functionality then only one remaining segment would be returned for both limits
EB*F*IND*3***32***P6*1~
MSG*Diabetic Education Program Visit Limit

EB*F*IND*3***32***P6*1~
MSG*Diabetic Education Follow-up Visit Limit

EB*F*IND*3***33***P6*1~

Submitter Assigned Keywords

EB03 Repeating Remaining

Response

Since the same Service Type Code must be used to communicate both of these benefits, it would not be appropriate to use the repeating function of the EB03 element for this.
If the specific benefits can be identified using procedure codes, then the following would be an example of how this could be communicated without using a MSG segment:

EB*F*IND****32***VS*2***HC|H1234~
EB*F*IND****33***VS*1***HC|H1234~
EB*F*IND****32***VS*2***HC|H5678~
EB*F*IND****33***VS*1***HC|H5678~

The above example shows a limitation of 2 lifetime visits for both procedures H1234 and H5678, with one visit remaining for each. The EB13 element can also be used to reflect a range of procedure codes, if applicable.

If however there are multiple procedure codes for each of these benefits, that do not constitute a defined range, and thus that cannot be returned using the EB13 element, then the appropriate response would be to continue to use a MSG segment for the time being, but to request new distinct Service Type Codes for use when the next mandated version of the transaction is brought forth.

The MSG text however should not include any elements that can be codified, such as “visit” or “limit”.
Submission 1/25/2013
Status Date 3/20/2013
Status F - Final
Primary References
Document 005010X279
Section2110 EB