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Back  RFI # 1755: 270 with 2100C EQ03 = 'FAM'

Formal vs. Informal Help Informal Formal

Submitter

bence gene

Description

The following statement in the 270/271 IG

The 271 response can only contain eligibility and
benefit information for the patient(s) identified in the 270 request unless the 270 request
contained a value of "FAM" in 2100C EQ03 and this level of functionality is supported
by the Information Source.

Does that mean there are no compliance issues with a payer sending back information in the 271 for only the Insured when there are multiple members in the family covered?

When a provider’s 270 has a value of ‘FAM in the EQ03, one of our payer clients is requiring only a match on the member id. If a match exists then they will return data for everyone in that family plan. None of the other Primary search options are used. Is there any compliancy or other issues with using only the member id to find a match? Since the one id is going to be used to report data on all members, should any members id be allowed or should it be only the subscribers id that is acceptable?

Submitter Assigned Keywords

2100C EQ03 = 'FAM'

Response

There are several issues addressed in this RFI, the support of returning all members of a family when 2110C EQ03 = FAM, if the patient’s Member ID is sufficient to match on and if so, is that match sufficient when returning all family members and whose Member ID should it be.

Both the Batch and Real Time portions of Section 1.4.3 of 005010X279A1 contains the following language “The 271 response can only contain eligibility and benefit information for the patient(s) identified in the 270 request unless the 270 request contained a value of "FAM" in 2110C EQ03 and this level of functionality is supported by the Information Source.”

The Situational Rule for 2110C EQ03 states “Required when the information receiver desires coverage information for an entire family and believes that the information source supports this functionality. If not required by this implementation guide, do not send”

2110C EQ03 has the following note regarding the support of this element “It is at the sole discretion of the information source whether to support this functionality or not. If not supported, information source will process without this data element.”

If a health plan (Information Source) chooses to support the functionality identified with the receipt of FAM in 2110C and return all of the Family members associated with the individual identified in 2100C, they would be in compliance with the requirements of the 005010X279 TR3 and 005010X279A1 errata. There would be no compliance issue for a health plan to ignore the value of “FAM” in 2110C EQ03 should they desire to not support this functionality.

With regards to what a health plan matches on to determine whether the health plan finds a match or not, so long as they support the requirements of Section 1.4.8 Search Options, a health plan is free to match on any subset of the Required Search Option or Required Alternate Search Options. Section 1.4.8.5 Alternate Search Options allows a health plan to identify any search option they desire to support, so long as they support the Required and Required Alternate Search Options. Since the Member ID is included in the Required and a number of the Required Alternate Search Options, it is compliant with the requirements of the 00501X279 and 005010X279A1 Errata to respond if a unique match is found for the subscriber based solely on the Member ID in 2110C NM109.

The 005010X279 TR3 and 005010X279A1 Errata do not create interdependent requirements on what search option is used should a payer choose to support the functionality of returning all family members if EQ03 = FAM. It would therefore be compliant to return all of the family members associated with the subscriber located if the 270 2110C EQ03 = FAM and it is a function the health plan choses to support. It would also be compliant should a health plan chose to have a more stringent matching criteria than just the Member ID when using the EQ03 = FAM functionality, so long as it no more stringent than the requirements outlined in Section 1.4.8 Search Options.

The 005010X279 TR3 and 005010X279A1 Errata is also silent on who in the family the match must be on and it would be up to the health plan if they wished to support this functionality for a match on just the policy holder, or also their spouse, of any family member or any combination of relationships. The choice would be up to the health plan.

Recommendation

While there are no requirements in the 005010X279 and associated 005010X279A1 Errata to return benefit and coverage information based solely on a match on the Member ID, caution should be used when matching solely on Member ID as there is a possibility of a mistyped Member ID in the request which would result in returning an incorrect Member’s benefits. WG1 would recommend matching on the Member ID and at least one additional piece of information such as the Subscriber’s Date of Birth. This would be particularly true in the case where the health plan also supports the functionality of returning all family members if EQ03 = FAM.
Submission 2/21/2013
Status Date 4/23/2013
Status F - Final
Primary References
Document 005010X279
Section1.1
Loop2110C
Segment Position1300
Segment IDEQ
Element Position03