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Back  RFI # 1916: medically necessary benefits

Formal vs. Informal Help Informal Formal

Submitter

Eric Scott

Description

We have dental plans which cover both medically necessary orthodontics and cosmetic orthodontics. These benefits may have different coinsurance, out of pocket amounts, maximums, etc. The benefits use the same service type code and procedure codes. How can I differentiate between the two in a 271 response?

Submitter Assigned Keywords

271 benefits medically necessary

Response

In the 005010X279 TR3, the use of the MSG segment to identify the reason for the orthodontic procedure is the only way to differentiate between cosmetic orthodontics and medically necessary orthodontics that use the same service types and procedure codes.

The TR3 note # 2 states "It is highly recommended that the entity needing to use the MSG segment approach X12N with data maintenance to solve the long term business need, so the use of the MSG can be avoided for that issue."

Recommendation:

The following verbiage is recommended for the MSG:

MSG*MEDICALLY NECESSARY~ or MSG*COSMETIC~

Please submit a change request through http://changerequest.x12.org/ for this business need with detailed requirements.
Submission 3/26/2014
Status Date 5/1/2014
Status F - Final
Primary References
Document 005010X279A1
Section2.6
Set ID271
Loop2110C