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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:

When returning base line response for 270 request, all service types associated with the baseline response must be sent with  benefit information  applicable for all services except  for Service type 1 ( Medical care ) and MH ( Mental Health). These two service types need to be returned with active or inactive status only.

Response

Section 1.4.7.1 - Minimum Requirements for Implementation Guide Compliance states in part:

8. “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.”

Section 1.4.4 reads in part “The specific information detail requirements and any type of health care eligibility or benefit inquiry or reply message is established by the business relationship between the transaction sets submitter and recipient organization.”

Absent a business agreement or legislative mandate more detailed benefit information for all service types that are covered benefits may be provided if it is applicable and available at the sender’s discretion including Service Types 1 and MH. The receiver cannot dictate for Service Types 1 and MH that only an active or inactive status be returned.

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 4/18/2014
Status F - Final
Primary References
Document 005010X279
Section2.6
Set ID271
Loop2100C