RFI Browser

Back  RFI # 2181: Multiple coverages same member

Formal vs. Informal Help Informal Formal

Submitter

Payson Adams

Description

Health plans are struggling with identifying benefits for their members who are enrolled in more than one product or more than one line of business. Plans are sending different values in 2100 EB04, 2110 EB05 and even 2110 REF to indicate that a service type is covered in one product or line of business and not in other products or line of business in the same 271 transaction. Is a 271 E&B response compliant when sending more than one 2110C EB01 status, Insurance Type, Product and group number for the same service type code in the same network? How can plans address multiple insurance types, products or lines of business for the same service type for the same member? Is this compliant? For example:

EB*1*IND*A3{42*HM*Plan 65 PREFERRED HMO MED/SURG 1002******U*W~
REF*6P*10093460 QCI*KS65 PREFERRED HMO RX P/B~

EB*I*IND*42**Plan FACILITY PLUS - HEARING ONLY*******W~
REF*6P*10121888 ZAX*BLUE EXTRA-PLUS~

Submitter Assigned Keywords

EB04, EB05, Group Number, Lines of Business, Multiple statuses

Response

Identifying coverage in more than one product or line of business becomes difficult when trying to bundle the benefits with those plans as there is no implied order of like segments in the transaction. A mix of either the 2110C/D EB01 + EB04 or EB05, or EB04 or EB05 and the 2110C/D REF must distinguish one plan from another.

The example provided is compliant with the TR3. It shows a covered benefit under Plan 65 PREFERRED HMO MED/SURG 1002 associated to Group 10093460 QCI KS65 PREFERRED HMO RX P/B. The example then shows that Home Health Care is a non-covered coverage, benefit or service under Plan FACILITY PLUS - HEARING ONLY associated to Group 10121888 ZAX BLUE EXTRA-PLUS.
Submission 12/6/2016
Status Date 3/1/2017
Status F - Final
Primary References
Document 005010X279
Section2.6
Set ID271
Loop2110
Segment Position1300
Segment IDEB
Element Position01
Industry NameEligibility or Benefit Information