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Back  RFI # 699: Multiple in-network tiers

Formal vs. Informal Help Informal Formal

Submitter

Delvis Schilling

Description

When a payer has medical plans that have more than one in-network tier, it presents an issue when trying to communicate benefit (co-payment/coinsurance) values in the 271. Currently, the payer populates the EB05 field with the network name (highest benefit, in-network). A question was submitted to the Minnesota AUC (Administrative Uniformity Committee) regarding how to send tiered benefits in the 271 response. The MN AUC response was to use the message segment to return the network name. The payer submitting the request to the MN AUC stated that the X12NTG2WG1 advised them to use the message segment to communicate the tier name. I would like an official ruling from X12 on how to communicate tiered benefits.

Ex. of how the payer currently returns tiered benefits:
~EB*B*IND*81**IN NETWORK*27*50*****Y
~EB*B*IND*81**HIGHEST BENEFIT*27*25*****Y

Ex. of how the payer will return benefits due to the MN AUC ruling:
EB*B*IND*81***27*50*****Y~
EB*B*IND*81***27*25*****Y~
MSG*Highest Benefit

Submitter Assigned Keywords

Multiple in-network tiers

Response

The two tiers represented in the example are for In-network Routine Physical Co-payments per visit, where one is $50 and one is $25 but the only distinction between the two is a note “Highest Benefit” for the $25 one. EB05 (Plan Coverage Description) is restricted to “the specific product name for an insurance plan” and should not be used for the purposes identified in this example. While the appropriate place for any benefit description that cannot be codified is the MSG01, the message of “Highest Benefit” does not seem to add any value or distinction between the two and would still force the provider to place a phone call to the payer to determine which amount to collect as a co-payment.

Recommendation

If a payer is going to make a distinction between benefits that cannot be codified, the appropriate place is MSG01, however it should be detailed enough to give the provider enough information to avoid having to make a phone call.

An even better response would have the payer determine which of the co-payments is applicable for the provider making the inquiry and only return the appropriate one.

NOTE: This is just one of many variations of "tiered" benefits and this response is applicable only to this example specifically.
Submission 10/21/2008
Status Date 11/21/2008
Status F - Final
Primary References
Document 004010X092A1
Section3.1
Page219
Set ID271