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Back  RFI # 719: Tiered Co-insurance

Formal vs. Informal Help Informal Formal

Submitter

Bob Resh

Description

For the Service Type Code "Substance Abuse" (EB03=AI), we have a tiered benefit such that the co-insurance amount varies based upon the number of services used in the year. i.e. - for services 1 to 10 the co-ins is 10%, for services 11 to 30 it is 25% and for all services after 30 it is 50%. We can't find any way to specify this benefit detail in the 271 using the EB or HSD segments. Are we correct that this type of benefit can't be completely reported in the 271? If it can be reported, please advise how to report it, or - should the MSG segment be used?

Response

The conclusion that this type of benefit can't be completely reported in the 271 is incorrect; this type of benefit can be completely reported in the 271. You can codify the various thresholds using the HSD segments. The MSG segment cannot be used for these purposes as this can be codified (per 004010X092 2110C and 2110D MSG segment note 2).

Recommendation

The following is an example of how the scenario described in the request could be codified:

Co-Insurance 10% 1 to 10 visits

EB*A*******.10~ (Co-Insurance 10%)
HSD***VS**31*10~ (Visits Not Exceeded 10)

Co-Insurance 25% 11 to 30 visits

EB*A*******.25~ (Co-Insurance 25%)
HSD***VS**30*10~ (Visits Exceeded 10)
HSD***VS**31*30~ (Visits Not Exceeded 30)

Co-Insurance 50% over 30 visits

EB*A*******.50~ (Co-Insurance 50%)
HSD***VS**30*30~ (Visits Exceeded 30)
Submission 1/5/2009
Status Date 5/19/2009
Status F - Final
Primary References
Document 004010X092A1
Section3
Page218
Set ID271
Table2
Loop2110CD
Segment IDEB