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Back  RFI # 542: 271 EB & AAA response

Formal vs. Informal Help Informal Formal

Submitter

chuck wilhelm

Description

HIR 224 was a request to clarify the minimum response to an inquiry in the EB segment. There has been some confusion as to the response to this HIR that I would like TG2/WG1 to clarify. We have seen payers respond with EB01 values from 1 to 8 in addition to AAA segments. For example EB01=5 (active pending investigation) & AAA67 (patient not found). These are conflicting responses and should not be considered more robust than just sending a AAA. 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."

Response

Section 1.3.7 identifies two compliant 271 responses. The first is to identify if the individual has active or inactive coverage and is based on the status of an individual that is found in the information source’s system. The second is for individuals who are not found in the information sources system. The two responses are mutually exclusive and noted by the use of the word “or” in the requirements statement.

Section 1.3.9 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.” “The AAA Request Validation segment is used to identify why an EB Eligibility or Benefit Information segment has not been generated or in essence, why the 270 Eligibility, Coverage or Benefit Inquiry has been rejected.”

Recommendation

HIR 224 addresses the minimum requirements for EB01 (Codes 1 through 8) when the individual is found in the information sources system, not for the requirement when the individual is not found.

Both Section 1.3.7 and 1.3.9 indicate one of the response types is required, not both. Returning an EB01 = 5 when the person is not in the database is not compliant with the implementation guide.

Returning both an AAA segment identifying an individual was not found and a coverage status is contradictory to the instructions and not compliant with the instructions indicating that one or the other must be returned. The above example should only have returned a AAA.
Submission 4/2/2007
Status Date 7/2/2007
Status F - Final
Primary References
Document 004010X092A1
Section1.3.7
Page20
Set ID271