RFI Browser

Back  RFI # 1869: Appropriate return of penalty

Formal vs. Informal Help Informal Formal

Submitter

Tricilla Muncy

Description

Payer has an Out of Network 25% precert penalty that applies when pre-certification is not obtained for Inpatient hospital benefits.

Per X12 (RFI 991)
“The MSG segment informing the provider of the % reduction in benefits if a preauthorization is not approved does not violate the message usage requirement.”

Which would be the correct way to report the OON benefit:
Sample 1
EB*1**30~
EB*1**48~
EB*B**48****0******~
EB*A**48*****.10*****Y~
EB*A**48*****.30***Y*N~
EB*A**48*****.25***Y*N~
MSG*THIS ADDITIONAL 25% PRECERT PENALTY APPLIES ONLY FOR NON-CERTIFICATION~
EB*C*FAM*30***23*400~
EB*C*IND*30***23*200~
EB*C**30***29*0~

Sample 2
EB*1**30~
EB*1**48~
EB*B**48****0******~
EB*A**48*****.10*****Y~
EB*A**48*****.30***Y*N~
MSG*THIS ADDITIONAL 25% PRECERT PENALTY APPLIES ONLY FOR NON-CERTIFICATION~
EB*C*FAM*30***23*400~
EB*C*IND*30***23*200~
EB*C**30***29*0~

Basically, would you code out the 25% as in sample 1 or just message the penalty as in sample 2?

Response

Sample 2 would be the most appropriate way to communicate this penalty. Sample 1 could be more easily misconstrued to incorrectly indicate that there is a second co-insurance applicable to out of network benefits, when it really is important to reflect the one 30% coinsurance with the separate 25% penalty.

Recommendation

Respond as in Sample 2 above, with a few corrections to the following:
•Remove element delimiters (*) after the last included element within the segment.
•Remove trailing 0s on end of percentages being reported
•Move Y to EB12 instead of EB13 in the co-payment segment
•Return the deductible amount remaining as it is for Family and Individual if that is how the base amounts are reported.
•Modify the MSG01 element as below to clarify that there is an additional percentage penalty for non-certification beyond the 30% co-insurance reported.

EB*1**30~
EB*1**48~
EB*B**48****0~
EB*A**48*****.1****Y~
EB*A**48*****.3***Y*N~
MSG*AN ADDITIONAL 25% PENALTY APPLIES IF NOT PRE-CERTIFIED~
EB*C*FAM*30***23*400~
EB*C*IND*30***23*200~
EB*C*FAM*30***29*0~
EB*C*IND*30***29*0~
Submission 10/11/2013
Status Date 2/14/2014
Status F - Final
Primary References
Document 005010X279A1
Section2110C