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Back  RFI # 1939: Variable FAM Deductible in 271

Formal vs. Informal Help Informal Formal

Submitter

Dean Bradley

Description

Hello,

My interpretation is regarding the ASC X12N/005010X279 and how to express a variable family deductible in the 271 transaction set.

In some benefit plans the family deductibles are not a fixed amount. In the example below, how should the family deductible information be expressed?
The plan has a $750 individual deductible and for the family deductible two members must meet the $750 individual deductible before the family deductible is satisfied. How is this to be reported in the response?

The following shows the Calendar year deductible for INDIVIDUAL Health Benefit Plan Coverage is $750.
EB*C*IND*30***23*750

The following shows the INDIVIDUAL Plan remaining deductible is $700.
EB*C*IND*30***29*700

How would we show the Calendar year deductible for FAMILY Health Benefit Plan Coverage is NOT $1,500, but is $750 INDIVIDUAL times 2?
EB*C*FAM*30***23*???

How would we show the FAMILY Plan remaining deductible is $750 INDIVIDUAL times 2?
EB*C*IND*30***29*???

Thank you for your time.

Response

The 005010X279A1 Technical Report Type 3 (TR3) does not explicitly address your question, nor does it provide a codified way to report the family deductible.

Therefore, it is appropriate to use the 2110C/MSG segment to convey the specific deductible information.

Here is an example based on a family with three members, each having an individual deductible of $750 and remaining individual deductibles of $700, $725, and $750 respectively. Since the family deductible is not met until two individual deductibles are met, the minimum remaining family deductible is the sum of the two lowest remaining individual deductibles or $700 + $725 = $1425.
Using the EB and MSG segments, this could be transmitted as-

EB*C*FAM*30***23*1500~
MSG*FAMILY DEDUCTIBLE SATISFIED ONLY WHEN 2 INDIVIDUAL DEDUCTIBLES ARE SATISFIED; MINIMUM FAMILY DEDUCTIBLE AMOUNT SHOWN~

EB*C*FAM*30***29*1425~
MSG*FAMILY DEDUCTIBLE SATISFIED ONLY WHEN 2 INDIVIDUAL DEDUCTIBLES ARE SATISFIED; MINIMUM REMAINING AMOUNT SHOWN~
Submission 5/29/2014
Status Date 7/7/2014
Status F - Final
Primary References
Document 005010X279
Section271
Loop2110C