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Back  RFI # 1851: 271 Explicit STC-Plan Inactive

Formal vs. Informal Help Informal Formal

Submitter

Deb McCachern

Description

RFI 1653 provides a description of the proper response to an explicit service type request when the member’s plan is active (see item 9 in Section 1.4.7.1 of the 005010X279A1 TR3).

What is the proper response to an explicit request when the member’s plan is inactive (EB01 of 6, 7, or 8)?

For example, suppose service type 98 is submitted in EQ01 of the 270 but the member’s plan is inactive. Is it sufficient to report a single EB loop showing inactive status for STC 30:

EB*6*30**PLANNAME~

or should the response also report the inactive status for STC 98 in an additional EB loop, as illustrated below?

EB*6*30**PLANNAME~
EB*6*98

And finally, should any benefit information be reported for STC 98, such as deductibles and copays, or inactive status, for example:

EB*6*30**PLANNAME~
EB*6*98
EB*B**98****10**VS*1~

Response

When the member’s plan status is inactive, the workgroup’s intent was that the 271 response include a single 2110C/D loop containing EB01 = ‘6’, EB03 = ‘30’, and EB05 = plan name (if one exists), along with no other 2110C/D loops containing any explicitly requested Service Type Codes. The workgroup acknowledges that this is not clearly noted in the front matter of the 005010X279A1 version of the ASC X12 270/271 TR3 document and will consider clarifying this within a future version.

Recommendation

The first example from the request would be the recommended response (corrected per the note below):

EB*6**30**PLANNAME~

Note: The example noted above was incorrectly formatted and was corrected in this recommendation. However, other required data elements and segments must also be a part of these noted 2110C loops when returned in an actual 271 response.
Submission 9/6/2013
Status Date 11/18/2013
Status F - Final
Primary References
Document 005010X279A1
Section1.4.7.1