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Back  RFI # 298: EQ segment in a 270

Formal vs. Informal Help Informal Formal

Submitter

Robert Huffman

Description

Is an EQ segment required in a 270 request? If a request is made for a subscriber does the request have to contain an EQ segment? The IG holds the EQ to be situational at the subscriber level and required at the dependent level. I think this means that if the request is for a dependent then the EQ must be used for the dependent and the EQ for the subscriber was not used for this situation. The situation where the subscriber is the focus of the request is vague in the 4010 version. The 5010 version is more straight forward.

Response

This issue is explicitly addressed in guide 004010X092. The second segment note for the 2110C loop and EQ segment reads "2. Use the EQ loop/segment when the subscriber is the patient whose eligibility or benefits are being verified. When the subscriber is not the patient, this loop must not be used." This note does not say "Can be used" or "Should be used". The wording is "Use this...". There is no ambiguity in the wording "Use this...".

At the 2000D/2110D loop, the EQ segment is required.

Therefore, whether the subscriber or dependent is the subject of the inquiry, an EQ segment at one location or the other is required for a 270 transaction that is consistent with this Implementation guide. A request made for a subscriber requires the use of the 2110C loop and EQ segment.

Without the inclusion of an EQ segment in a 270 transaction, you do not have an Eligibility Request.

Recommendation

The appropriate response to a 270 transaction without an EQ segment would contain an EB01= V (Cannot Process) in the 2110C and a 2110C AAA with a AAA03 = 15 (Required application data missing).

The 005010 Draft Implementation Guide has clarified the requirement of the EQ segment in loop 2110C as follows:

Required when the subscriber is the patient whose eligibility or benefits are being verified. If not required by this implementation guide, do not send.
Submission 8/8/2005
Status Date 11/11/2005
Status F - Final
Primary References
Document 004010X092A1
SectionEQ
Page89
Set ID???