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Back  RFI # 342: Active/Inactive Coverage

Formal vs. Informal Help Informal Formal

Submitter

Doug Fielding

Description

New York Medicaid is returning 271 eligibility response transactions that do not, at a minimum, indicates either Active Coverage, or Inactive Coverage in EB01 (Loop 2110C or 2110D). They are only sending more detailed values and not a 1 thru 8 value. I am requesting confirmation that my interpretation of the IG is correct, in that a payer must at a minimum, provide an EB01 with a value of 1 or 6, or even any value of 1-8, to indicate whether the coverage is Active or Inactive, and independent of any other detail that they send. Correct?

Submitter Assigned Keywords

eligibility response active inactive coverage EB EB01

Response

This issue is explicitly addressed in guide 004010X092. Section 1.3.7 states "An information source must respond with either an acknowledgment that the individual has active or inactive coverage or that the individual was not found in their system." Note number 5 on the EB segment states "The minimum data for a HIPAA compliant response for a person that has been located in the information source’s system must indicate either, 1- Active Coverage or 6 - Inactive in EB01 and, 30 - Health Benefit Plan Coverage in EB03. Information sources are not limited to the minimum HIPAA compliant response and are highly encouraged to create as elaborate a response their systems allow...".

Since EB01 values 2, 3, 4, 5, 7 and 8 provide more detail, they are acceptable values to meet the requirements. Therefore, for a 270 request where the person is found within the payer's system, the response 271 must have an EB segment with an EB01 value of 1 through 8. See HIR 224 for addition information.
Submission 10/19/2005
Status Date 12/6/2005
Status F - Final
Primary References
Document 004010X092A1
Section3
Page218
Set ID???
Table2
Loop2110C
Segment Position130
Segment IDEB
Element Position01
Industry NameEligibility or Benefit Information
Code Value1-8