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Back  RFI # 2265: CPTs on the 270

Formal vs. Informal Help Informal Formal

Submitter

Boyle-Campbell Donna

Description

When a 270 contains only CPT codes and no Service Type Code, is the expectation to return the STCs associated with a 30 if the CPT is used to address pre-authorization requirements only-not to determine if the CPT is a covered service or not?

We are looking for direction on what the definition of "support" means on the 270 EQ02 note (If an inquiry is submitted with EQ02 and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of “30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.4.7 for additional information.)

Also, would items 1-7 be required then if only CPT was submitted and used for pre-auth requirements only? We ask, because, it seems most of the front matter defining the requirements for what must be returned are geared toward service type codes; this seems to leave a lot of room for interpretation on CPT codes.

Response

Section 1.4.7.1 addresses the minimum required data that must be returned in a 271 response. If the individual submitted in the 270 is in the information source's system, then items listed under 1 to 7 within this section must be returned.

When a 270 contains a CPT code, the responder may indicate whether the code requires a prior authorization or not. The responder is not required to return the same data elements that would have been returned if a service type code was submitted.

Recommendation

While additional information is not required to be included in the response, returning comprehensive patient benefit information is a best practice.
Submission 1/10/2018
Status Date 3/1/2018
Status F - Final
Primary References
Document 005010X279A1
Section2
Page130
Set ID270
Table2
Loop2100C
Segment Position1300
Segment IDEQ
Element Position02
Component PositionC0
Industry NameCOMPOSITE MEDICAL PROCEDURE IDENTIFIER
External Code List133
Code ValueN/A
Secondary References
RFI ID 2747
Document 005010X279A1
Section1.4.7.1
Page19