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Back  RFI # 2014: Remaining Cov Benefits GiC 271

Formal vs. Informal Help Informal Formal

Submitter

Tammy Feenstra Banks

Description

More and more providers are requesting payers to report the patient’s remaining covered benefits or gaps in care information to satisfy value-based payment or other agreement requirements. Not all of the remaining benefits or gaps in care can be reported with a CPT or other code.

Examples of Remaining Gaps in Care Benefits / CMS Star Rating Program include:
C01-Colorectal Cancer Screening
C04-Annual Flu Vaccine
C07-Monitoring Physical Activity
C08-Adult BMI Assessment

One payer is utilizing the 2110C MSG segment to report this information. Is the following example an appropriate way to report outstanding benefits or gaps in care on the 271?

Report measure on loop 2110C, MSG Segment, Element MSG01, Free-Form Message Text

2110C - Each MSG segment can hold up to 264 characters, but it can repeat up to 10 times.

If not, what options are there to provide a provider with a patient’s outstanding benefits and/or Gaps in care on the 271 in order to provide a complete benefit picture.

Submitter Assigned Keywords

gaps in care, remaining covered benefits,

Response

If the payer supports procedure code level inquiry and/or responses, and the gap in care is represented by more than one procedure code, the payer is required to return the gap in care using the EB13 element or multiple EB segments. If a single or range of procedure codes is/are not available, there is no Service Type code that can be used, and no other way is available to ‘codify’ the gap in care, OR if there is a procedure or Service Type code available to be returned in the EB segment and more information that the procedure or service is available as part of that member’s preventive or care management plan, returning an MSG segment containing verbiage that the benefit is part of the member’s preventive or care management plan is appropriate. A corresponding DTP01 value indicating the benefit date that benefit is available, or, if needed, the date of last visit or consultation may be returned.

Recommendation

You may submit a Change Request if you have a business need not supported in a published TR3, and/or to request a more explicit way to indicate that a service or benefit is available for the patient as a part of that patient’s preventive or care management plan. Change requests are submitted at http://changerequest.x12.org/
Submission 2/23/2015
Status Date 8/26/2015
Status F - Final
Primary References
Document 005010X279
Section?
PageNA
Set ID271
Table?
Loop2110C
Segment PositionMSG
Segment IDMSG
Element Position?
Component PositionNA
Industry NameFree- Form Message Text
External Code ListNA
Code ValueNA