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Formal vs. Informal Help Informal Formal

Submitter

Sharon Copeland

Description

We would like to know if this client request is valid:

A ‘Baseline’ or our ‘standard’ response must include the appropriate response information for the following service types, when they apply to the member’s coverage.   For each of these Service Types we would indicate whether In-Network or Out of Network applied, Co-pay and/or Coins when applicable, and In/Out of Network Deductibles.  

1 Medical Care (Active or Inactive Only)
30 Health Plan Benefit Coverage
33 Chiropractic
35 Dental
47 Hospital
48 Hospital Inpatient
50 Hospital Outpatient
51 Hospital Emergency Accident-
52 Emergency Room
86 Emergency Services
88 Pharmacy
98 Physician Office Visit
AL Vision
MH Mental Health (Active or Inactive Only)
UC Urgent Care
BY Physician Visit Office: Sick
BZ Physician Visit Office: Well

MSG01= SPECIALIST

Only return active (EB01=1) or inactive (EB01=6) for service types 1 (Medical Care), MH (Mental Health).

Response

Guide section 1.4.7.1 # 8 explicitly requires the following Service Types in a general response:

1 Medical Care
30 Health Plan Benefit Coverage (active or inactive only)
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

There is no restriction on MH being Active or Inactive only. There is no mention in the guide for the use of the MSG01 with SPECIALIST - see RFI 1779 for more. There is no restriction to only send codes for active or inactive with Service Type 1. The recommendation for including information about Co-pay and/or Coins, when applicable, and In/Out of Network (if applicable) deductibles is in section 1.4.7.2. Per guide section 1.4.7.2, codes 48, 50, 51 and 52 are components of Service Type Code 47 (Hospital), and are recommended but not separately required.

Recommendation

Additional requirements due to Federally mandated Operating Rules may apply. See http://www.caqh.org/CORE_operat_rules.php for detailed information about operating rules.
Submission 3/6/2014
Status Date 5/16/2014
Status F - Final
Primary References
Document 005010X279
Section2.6
Set ID271
Loop2110C