RFI Browser

Back  RFI # 505: Payer TPL reporting

Formal vs. Informal Help Informal Formal

Submitter

KEN EDICK

Description

Is it appropriate for one payer to use an Active Coverage EB01=1 code for another payer?

Specifically, Medicaid plans often identify Medicare Part A & B with an EB01=1 instead of using EB01=R 'Other or Additional Payor'. When this is questioned, the Medicaid staff (or vendor) suggest that since they have information indicating that a recipient has Medicare coverage they are allowed to report it. When we suggest that Medicare should be reported as TPL using EB01=R and the provider should send a separate Inquiry to Medicare to determine eligibility status they respond that the IG doesn't provide any guidance in this area.

Section 1.3.1, second paragraph, states "The information source organization may provide information about other organizations that may have third party liability for coordination of benefits." Can this be interpreted to mean that reporting of other payers for TPL requires the use of the EB01=R?

Submitter Assigned Keywords

eligibility tpl

Response

Section 1.3.1 indicates that the Information Source “may provide information about other organizations that may have third party liability for coordination of benefits”. The key point in this statement is “about other organizations”; it does not indicate that any details such as Coverage Status may be provided. The appropriate method for providing information about other organizations is by use of 2110 EB01 = R (Other or Additional Payor) with a 2120 loop identifying the other organization (i.e. name, identifiers, address and contact information).

The intent of the guide is that the Information Source will respond with definitive benefit and eligibility information only when they are the authoritative information source related to that information, not to provide any detailed information (such as coverage status or benefits) for other payers, only to identify other payers. It would not be appropriate to indicate an EB01 = 1 for another payer or plan for whom they are not the Information Source.

Recommendation

Providing information beyond identifying an organization that may have TPL/COB involvement would not only be inappropriate it may be inaccurate, misleading or misinterpreted. Upon receiving a 271 that identifies another payer, it would be appropriate for the Information Receiver (typically a provider) to contact the other payer identified directly with another 270 transaction to determine eligibility and benefit coverage for the individual.

This issue has been addressed in subsequent versions of the 270/271 Implementation Guide. The Version 005010 Implementation Guide for the 270/271 requires the following if an individual is found in the information source’s system: “Other payers or plans if known in 2120C/D. (Note: Do not return details of coverage or benefits associated with other payers or plans, the Information Receiver should initiate a separate 270 request to the other payer or plan to determine the level of coverage.)”
Submission 1/5/2007
Status Date 2/27/2007
Status F - Final
Primary References
Document 004010X092
Section3.1
Page218
Set ID271
Table2
Loop2110C
Segment Position218
Segment IDEB
Element Position01
Industry NameEligibility or Benefit Information
External Code ListInternal DE 1390
Code ValueR