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Back  RFI # 1779: PCP vs Specialist Copays 271

Formal vs. Informal Help Informal Formal


Ann Sherman


How do we represent the Physician Visit – Office (BY&BZ) Copays when we have a different Copay for PCP versus Specialist Office visits. This is not their assigned PCP, but a provider who is a PCP Type provider – General Practice, DO, Internal Medicine….vs a Specialist – Cardiologist, etc.

Here are a few examples:

Example1-the PCP Copay is $30, Specialist is $50

Example2-The PCP is $10 copay,
Specialist with a referral is $20 Copay
Specialist without referral the Copay is $50

Example3-Ties the PCP/Specialist Differential also in with the Network Tiers:
• The PCP is $20 copay for Tier 1, $35 Copay for Tier 2 then 70/30 after deductible, OON $45 Copay then 50/50 after deductible
• The Specialist is:
• With referral is $30 copay for Tier 1, $40 Copay for Tier 2 then 70/30 after deductible, OON $50 Copay then 50/50 after deductible
• Without referral is $40 copay for Tier 1, $50 Copay for Tier 2 then 70/30 after deductible, OON $50 Copay then 50/50 after deductible

Submitter Assigned Keywords

PCP vs Specialist Office Visit Copay differentials


There are a number of concepts associated with co-payments in this RFI, each concept is addressed individually.

Co-payment information is identified in EB07 with “B” in EB01. For example, if the patient’s co-payment is $10 then the value in EB07 would be “10”.

The 005010X279 and associated errata allow for the use of the MSG segment when items cannot be codified elsewhere in the response. There is no codified solution to identify “Specialist” so you may include “Specialist” in the 2110 MSG01 for the 2110 loop with the co-payment information codified appropriately.

EB11 = 'Y' is used to report the requirement for an authorization, or certification related to the benefits described in a specific 2110 loop, as per the 005010X279 and associated errata. The 005010X217 “Heath Care Services Review – Request for Review and Response“ TR3 should be consulted, specifically section 1.5 Business Terminology, for definitions of the terms “Referral”, “Authorization” and “Certification”. EB11 values “Y” and “N” would be used to identify the requirement or lack of a requirement for authorization related to the benefit. Two 2110 loops are needed with different EB11 values to identify different benefits based upon authorization or certification.

In or Out of Network
When benefits differ In Network or Out of Network, use EB12, with Y to indicate In Network, N to indicate Out of Network, to describe the different benefits.

There is no codified solution to indicate multiple Tiers that apply In Network, so you may indicate the appropriate Tier in the MSG segment. This may be combined with the “Specialist” MSG if applicable.

The patient’s portion of Co-Insurance responsibility is reported in EB08 with EB01 = “A”. If the patient’s co-insurance percentage is 30 %, the value in EB08 would be “.3”, if it were 50% the value in EB08 would be “.5”.

All of these items may be used together, as appropriate, to form the 2110 loops identified in your examples.

When EB11 = ‘Y’ is used to represent either a Referral Authorization or “Specialist” Referral as described in section 1.5 of 005010X217, it is recommended that a related 271 2110 MSG segment accompany this 2110 EB segment indicating which “type” of referral the plan provisions require.
Submission 4/16/2013
Status Date 7/31/2014
Status F - Final
Primary References
Document 005010X279