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Back  RFI # 2237: 271 III Exclusion

Formal vs. Informal Help Informal Formal

Submitter

Anderson Kelly

Description

Please explain the compliant use of the 5010x279 III segment and/or other segments to convey place of service in the following scenario:

A benefit is structured such that there is a 20% coinsurance for service rendered in any place of service except office. The same service rendered in the office place of service has a 10% coinsurance. How should the 20% coinsurance be conveyed with respect to the III segment since it is essentially "any place except"?
Is the following acceptable? Or would a MSG segment be needed?

EB*A*IND*9***27**.2****W~
EB*A*IND*9***27**.1****W~
III*ZZ*11~

Response

Your example is compliant with the 005010X279A1 TR3; however, in this 5010 TR3 there is not a codified way to explicitly indicate the exception logic in the 2110C or D loop alone. The authors of the TR3 recommend the use of the MSG segment and 2115 loop as follows:.

EB*A*IND*9***27**.2****W~

MSG*Applies to all places of service except Office~

EB*A*IND*9***27**.1****W~
III*ZZ*11

In subsequent versions of the 271, the loop repeat of the 2115C and 2115D loops was increased to 100 to accommodate more Facility Type Codes.

Recommendation

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 9/15/2017
Status Date 12/8/2017
Status F - Final
Primary References
Document 00510x279
Section2
Set ID271
Loop2115
Segment IDIII