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Back  RFI # 1852: 271 Rsp to 30 w/ Ntwk Variance

Formal vs. Informal Help Informal Formal

Submitter

Deb McCachern

Description

Section 1.4.7.1 of the 005010X279A1 TR3 describes the response to a 270 where EQ01 = 30 by indicating that service types 1, 22, 23, 47, 56, 88, 98, AL, MH, and UC must be returned “if they are a covered benefit category at a plan level.” Item 8 also indicates that “If it is not a covered benefit, the code must not be returned.”

What is the proper response when one of the service types listed in item 8 is covered for in-network benefits but not covered for out of network benefits? We have encountered a situation where STC 35 is covered for in-network providers only.

Which example below would be a correct?

Return one EB loop for the active in-network coverage and one showing that out-of-network is not covered:
EB*1**35**PLANNAME*******Y~
EB*I**35**PLANNAME*******N~

Or simply one EB loop for the active in-network coverage, with no EB loop returned to reflect the lack of out-of-network coverage:
EB*1**35**PLANNAME*******Y~

Response

The first example would be correct.

The 005010X279A1 2100C/D EB12 Situational Rule states:

Required when needed to indicate if benefits are considered In Plan
Network or Out Of Plan Network for the eligibility or benefits being identified
in the 2110C loop. If not required by this implementation guide, do not send.

As such, since the benefit is covered in network but not covered out of
network, it would be compliant to return both scenarios for the benefit.

Further, this is not a
conflict with the requirements of Section 1.4.7.1 271 item 8 which
states:

“If an information source receives a Service Type Code "30" submitted
in the 270 EQ01 or a Service Type Code that they do not support, the following
2110C/D EB03 values must also be returned if they are a covered benefit
category at a plan level.

1 - Medical Care
33 – Chiropractic
35 - Dental Care
47 - Hospital
86 - Emergency Services
88 - Pharmacy
98 - Professional (Physician) Visit - Office
AL - Vision (Optometry)
MH - Mental Health
UC - Urgent Care

The above codes must have the
appropriate EB01 = 1-5. If it is not a covered benefit, the code must not be
returned. The repetition function of EB03 must be used if only reporting the
Active Status or if Patient Responsibility is the same across multiple
benefits. If any of the above benefits are associated with another entity (e.g.
carve out) the information must be returned in 2120C/D if known”

Since the benefit is covered at a plan level, however is not covered when
out of network, the restriction of not identifying non-covered benefits does
not apply.
Submission 9/6/2013
Status Date 12/5/2013
Status F - Final
Primary References
Document 005010X279A1
Section1.4.7.1