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Back  RFI # 2059: Patient Responsibility

Formal vs. Informal Help Informal Formal

Submitter

Albetski Allan

Description

On some plans, patient responsibility applies only after a benefit dollar limit has been met or exceeded.

e.g., $1500 is an earmarked benefit that a member will receive for DME service only. The payer will pay up to $1500 for this benefit and after that amount is paid the member will share the cost of patient responsibility (i.e. deductible, coinsurance etc.).

So $1500 is the benefit limit that member gets and not the cost share/patient responsibility that member pays.

My attempt is as follows:
EB*1*IND*18**PLANNAME*24*0****W
EB*G*IND*18**PLANNAME*23*0****W
MSG*PATIENT RESPONSIBILIY APPLIES AFTER FIRST $1500 OF BENEFIT PAID
EB*A*IND*18**PLANNAME*23**.2***W
MSG*PATIENT RESPONSIBILIY APPLIES AFTER FIRST $1500 OF BENEFIT PAID

I would appreciate your thoughts on my attempt
The EB*1 is an attempt to indicate the amount already paid year to date for this benefit

Submitter Assigned Keywords

271 Patient Responsibility

Response

There is currently not a value in the EB01 of the 005010X279A1 271 TR3 to specifically represent this benefit.

Recommendation

EB*1*IND*18**PLANNAME~

EB*D*IND*18**PLANNAME*23*1500****W~

MSG*PATIENT RESPONSIBILITY APPLIES AFTER FIRST $1500 OF BENEFIT PAID~

EB*D*IND*18**PLANNAME*29*1500****W~

MSG*PATIENT RESPONSIBILITY APPLIES AFTER FIRST $1500 OF BENEFIT PAID~

EB*A*IND*18**PLANNAME*23**.2***W~

MSG*PATIENT RESPONSIBILITY APPLIES AFTER FIRST $1500 OF BENEFIT PAID~


If you have a business need not supported in a published TR3, you may submit an ASC X12 change request for consideration in a future version of the TR3. Change requests are submitted at http://changerequest.x12.org/
Submission 5/29/2015
Status Date 8/27/2015
Status F - Final
Primary References
Document 005010X279A1
Section1.4.9