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Back  RFI # 205: 271 - Coinsurance Amount

Formal vs. Informal Help Informal Formal

Submitter

Megan Soccorso

Description

I am looking for some guidance in the 271 transaction. When an amount is being sent back identifying coinsurance (EB segment) – does the amount/percent reflect what the patient is responsible for or should it reflect the amount that the payer will pay? So for example, if the patient was responsible for 10% of services should the 10% be reflected or the 90% that the payer will pay be reflected?

Response

The intention of the Implementation Guide 004010X092 is to return the patient’s portion of responsibility when returning Co-insurance, Co-payment, Deductible, Out of Pocket (Stop Loss) or Spend Down. In the case of the request, the value returned in EB08 would be .10 or .1 indicating 10% Co-insurance as the patient’s portion of responsibility.

Newer versions of the 270/271 Implementation Guide will contain a new section entitled Patient Responsibility and identifies when returning Co-insurance, Co-payment, Deductible, Out of Pocket (Stop Loss) or Spend Down the values returned are to reflect the patient’s portion of responsibility.
Submission 2/17/2005
Status Date 5/16/2005
Status F - Final
Primary References
Document 004010X092
SectionEB Sgmnt
Page229
Set ID271
Loop2110
Element Position07
Industry NameBenefit Amount