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Back  RFI # 521: 271 co-pay not flat $ amt

Formal vs. Informal Help Informal Formal

Submitter

Cathy Prehodick

Description

I'm not sure how to correctly report a co-pay that is not a flat dollar amount. We have plans that can also be a percentage, the greater of the dollar amount and the percentage or the lesser of the dollar amount and the percentage. I can give both the dollar amount and the percentage but the provider wouldn't know if they were to use the greater of the two or the lesser of the two.

Submitter Assigned Keywords

271 co-pay

Response

It would be inappropriate to report all of these values as Co-Payment. The 004010X092A1 Implementation Guide and Addenda identifies more options for reporting this type of information. The Co-payment dollar amount is reported in EB07 with EB01 = B. The percentage based patient responsibility should be reported as Co-Insurance and is reported in EB08 with EB01 = A.

There is no codified solution to convey that the greater (or lesser) of the two applies to the benefit so it would be appropriate to use the MSG segment. Use a MSG segment for each occurrence of the co-payment and the corresponding co-insurance EB segments.

By way of an example for a Generic Prescription Drug (EB03 = 92) that has a $15 co-payment OR a 25% co-insurance of which the greater of the two must be paid by the patient:

EB*A**92*****.25~
MSG*CO-PAYMENT OR CO-INSURANCE WHICHEVER AMOUNT IS GREATER~
EB*B**92****15~
MSG*CO-PAYMENT OR CO-INSURANCE WHICHEVER AMOUNT IS GREATER~

Recommendation

For the scenario where the greater of the two amounts applies the provider will collect the Co-payment initially, and upon receipt of payment of the claim, they will determine if the patient has additional financial responsibility that is met by the collection of the remaining amount due identified as Co-Insurance responsibility (Co-Insurance minus Co-Payment collected equals Balance Due). Where it is the lesser amount, the provider will likely have to wait until they receive payment for the claim to determine which amount is the lesser to collect from the patient.
Submission 2/21/2007
Status Date 7/2/2007
Status F - Final
Primary References
Document 004010X092A1
SectionDetail
Page218
Set ID271
Table2
Loop2110C
Segment Position130
Segment IDEB