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Back  RFI # 1930: Multiple Benefit Network Tiers

Formal vs. Informal Help Informal Formal

Submitter

Kenneth Greenspan

Description

If a trading partner sends multiple benefit network names in the 271, can the EB05 data element be used to return different benefits? Please see the Copay & Deductible example below. My understanding based on RFI’s 699, 1690, and 1767 is that it is inappropriate to send multiple benefit responses that are only distinguishable by EB05. If a partner sends data with this structure, is it considered a non-compliant transaction which should be rejected by the receiver, or is it really that this EDI structure is not best practice but can be accepted by the receiver?

EB*B*IND*98**Benefit Name 1**2**S7*125**Y~
EB*C*IND*98**Benefit Name 2*23*135*****Y~
EB*C*IND*98**Benefit Name 2*29*135*****Y~
EB*B*IND*98**Benefit Name 3**4**S7*125**Y~
EB*B*IND*98**Benefit Name 4**6**S7*125**Y~

Submitter Assigned Keywords

Tier Benefit EB05

Response

The note for 2110C/D EB05 reads "This element is to be used only to convey the specific product name or special program name for an insurance plan.... This element must not be used to give benefit details of a plan."

The 2110C/D REF allows for a qualifier N6 "Provider Plan Network Identification Number" which would require use of the REF02 (for the number itself) and then allow use of the REF03 to communicate the network name.

The 2120C/D loop Subscriber/Dependent Benefit Related Entity Name loop, NM101 code 1I - Preferred Provider Organization (PPO) note includes "May also be used if identifying the Network that benefits are restricted to when 2110C EB12="Y" (In-Network)."

Therefore, your stated usage of EB05 is not compliant with the guide. Identification of the network for specific benefits is handled using the 2110 C/D REF with REF01 code N6 when the network is owned by the Information Source and there is a identifier for the network. The 2120C/D loop, with NM101 code 1I, is used when the network is owned by a related/other entity or there is no network identifier that could be included in the 2110C/D REF02 .

Separate 2110C loops are used for each benefit/network combination, thus separating the network benefits.

Action by a trading partner that receives a non-compliant transaction is discussed in RFI # 1512.
Submission 4/18/2014
Status Date 5/16/2014
Status F - Final
Primary References
Document 005010X279
Section2
Page299
Set ID271
Table2
Loop2110CD
Segment Position1204
Segment IDEB
Element Position05