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Back  RFI # 1778: EB01 = ACTIVE or INACTIVE

Formal vs. Informal Help Informal Formal

Submitter

Tucker David

Description

We currently have a state mandate (CO State Mandate - House Bill 1353) that if an insured gives back incorrect eligibility information then they are prevented from taking back any monies paid in error.
Whe we have an member on an INDIVIDUAL policy in the state of Colorado who fees are not paid to date and in their grace period we would like to return an EB01=V (cannot process) or EB01= U (contact entity for eligibility and benefit information) without returning an EB01 = 1 - 8 but need to clarify this is not against the TR3.

The TR3 front matter states the following:
"For each plan for which the individual has active or inactive coverage, a 2110C/D loop is required with EB01 Status = 1, 2, 3, 4, 5, 6, 7 or 8 with 2110C/D EB03 Service Type Code = 30 (Health Benefit Plan Coverage) and Plan Name in EB05 if one exists."

In the siutaton where the member is not up to date on his fees, during his grace period, the member is NOT active or inactive.

Submitter Assigned Keywords

CO State Mandate

Response

A major intent behind the usage of Electronic Transactions in the Healthcare industry is to reduce the volume of phone calls made to payers and to provide a useful response to a provider in a reasonable amount of time so that they can most effectively conduct business. The 271 Eligibility Response is not meant to imply a guarantee of payment or coverage and typically occurs prior to any payment being issued. Therefore, a mandate that no monies paid in error can be refunded, would apply to the payer’s claim’s adjudication process and any eligibility determinations made within that.

Recommendation

The most appropriate response in this situation would be to return a full 271 response, using EB01 = 5 (Active – Pending Investigation).

The health plan should clearly explain to the provider community that they do business with in Colorado, that EB01 = 5 received on a 271 response indicates that in fact a claim submitted for this patient may not be paid. This would give the providers that additional piece of information, along with other eligibility and benefit details, in order to make an informed decision to collect payment or not, without having to make expensive and time consuming phone calls. If the Health Plan feels this needs to be more clearly represented, a MSG segment could be included containing the text from the legislation quoted in MSG01 - "ELIGIBILITY IS CONTINGENT ON PAYMENT OF THE PREMIUM DUE AND THAT ELIGIBILITY CANNOT BE CONFIRMED FOR THE PERIOD THAT THE PREMIUM IS OUTSTANDING".

The health plan may also return a 2100C DTP with DTP01 = 343 (Premium Paid To Date End), DTP02 = D8, and the date that premiums have been paid through to, and 2110C loop DTP segments reporting "193" (Period Start) and "194" (Period End) with the beginning and end dates of the grace period.
Submission 4/15/2013
Status Date 8/26/2013
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1