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Formal vs. Informal Help Informal Formal

Submitter

Doreen Espinoza

Description

Background:Union Contracts allow for medical coverage of the union member, after a minimum number of hours worked has been met. Benefit management companies provide the eligibility information to providers as a month to month eligibility when queried. Before benefit management companies begin using the transaction they would like to understand how to provide eligibility in the following scenario.

Scenario:The "hours worked" information is not submitted to the benefit management until after the first of the month. This places eligibility inquiry responses in a unique situation for a few days at the beginning of each month. During the time period from the end of the previous month until the hours worked are submitted the eligibility is under determination, so it’s not really a hard “yes” or “no” response.
How can the 271 be constructed to provide a response that gives the following information?
Eligibility is still being determined
There has been continuous coverage for this member since xx/xx/xxxx date

Submitter Assigned Keywords

Union Contracts

Response

In this scenario, the benefit management can choose to return eligibility status as "Active - Pending Investigation" or "Inactive - Pending Investigation" during this period under determination.

The following EB and DTP segments would convey the intended information, which is:
  • Eligibility is still being determined
  • There has been continuous coverage for this member since mm/dd/yyyy date
If the 270 is sent with STC 30, "Active - Pending Investigation" status can be conveyed in the 271 as:

DTP*346*D8*yyyymmdd~
EB*5**30**PLAN NAME if applicable~

Section 1.4.7.1 of the 270/271 5010 TR3 elaborates further on minimum requirements for a 271 response.

While EB01 values 5 or 7 can also be used to convey "Pending" status, EB01 = 5 would be more appropriate to convey "There has been continuous coverage...".
Submission 7/9/2015
Status Date 8/26/2015
Status F - Final
Primary References
Document 005010X279
Section2110C EB