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Back  RFI # 1762: Use of an EB and AAA

Formal vs. Informal Help Informal Formal

Submitter

Boyle-Campbell Donna

Description

We have business situations where we feel returning an AAA in addition to an EB is necessary. Such as, we cannot respond with benefits covered under a particular policy (EB*V and an AAA 42 at the 2100A level), but can return member demographic or plan information. We sometimes too return an AAA 72, but additionally return the EB*P with a disclaimer message (MSG).

Is returning an AAA 42 or AAA 72 and an EB*V or an EB*P (respectively) a violation of the 005010X279 TR3? Please address both situations (AAA 42 + EB*V and AAA*72 + EB*P + MSG) and any others that speak to the example

Submitter Assigned Keywords

EB AAA

Response

The Situational Rule for the 2110C EB segment states that it is "Required when the Subscriber is the person whose eligibility or benefits are being described and the transaction is not rejected or if the transaction needs to be rejected in this loop. If not required by this Implementation Guide, do not send." Additionally, Section 1.4.10 of the TR3 states "A 271 Eligibility, Coverage or Benefit Information response transaction must contain at least one EB (Eligibility or Benefit Information) segment or one AAA (Request Validation) segment." The section further states "The AAA Request Validation segment is used to identify why an EB Eligibility or Benefit Information segment has not been generated or in essence, why the 270 Eligibility, Coverage or Benefit Inquiry has been rejected".

Returning both a AAA Request Validation segment rejecting the 270 inquiry and a 2110C(or 2110D) EB loop is only permitted when the AAA error exists within that respective 2110C or 2110D level. Returning the AAA/EB pairings referenced in the request is contradictory to the usage instructions within Section 1.4.10 as well as the Situational Rule governing the use of the EB segment, and therefore not a compliant usage of the TR3.
Submission 3/8/2013
Status Date 4/9/2013
Status F - Final
Primary References
Document 005010X279
Section2
Page393
Set ID271
Table3
Loop2100C
Segment Position1300
Segment IDEB
Element Position01
Code ValueP
Secondary References
RFI ID 2235
Document 005010X279
Section1
Page227
Set ID271
Table2
Loop2100A
Segment Position0850
Segment IDAAA
Element Position03
Code Value42