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Back  RFI # 2076: reporting of actuals

Formal vs. Informal Help Informal Formal

Submitter

Amy Wiener

Description

Good morning,

We have a provider that is asking how to report on the below:
We have BP plans that are not subject to a maximum number of visits. Here is an example where they pay a $20.00 copay for the 1st 50 visits and then have a 20% coinsurance for any additional services.

Outpatient rehabilitative therapy:
up to 50 visits per year
$20 copay per visit - once maximum is met add'l visits are subject to OON cost share
20% co-insurance after plan deductible

My attempt:
EB*1*IND*98**HMO OA CAL HSA1500
EB*B*IND*98**HMO OA CAL HSA1500*27*20**VS*50*Y
MSG*Once maximum is met additional visits above 50 are subject to OON cost share
EB*A*IND*98**HMO OA CAL HSA1500*23*.2****Y
MSG*plan subject to co-insurance after plan deductible met
REF*1L*002030

Response

TR3 note 2 of the MSG segment reads: “2. Under no circumstances can an information source use the MSG segment to relay information that can be sent using codified information in existing data elements (including combinations of multiple data elements and segments). Information that has been provided in codified form in other segments or elements elsewhere in the 271 for the individual must not be repeated in the MSG segment. If the information cannot be codified, then cautionary use of the MSG segment is allowed as a short term solution. It is highly recommended that the entity needing to use the MSG segment approach X12N with data maintenance to solve the long term business need, so the use of the MSG segment can be avoided for that issue.”

The benefit that you describe can be codified in the 005010X279A1 271 as follows:

EB*1*IND*98**HMO OA CAL HSA1500
EB*B*IND*98**HMO OA CAL HSA1500*27*20****Y~HSD***VS**31*50~

EB*A*IND*98**HMO OA CAL HSA1500*23*.2****Y~ HSD***VS**30*50~
Submission 7/23/2015
Status Date 12/7/2015
Status F - Final
Primary References
Document 005010X279
Section2.5.1