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Back  RFI # 774: 5010 271 EB12=W usage

Formal vs. Informal Help Informal Formal


Jennifer Delmont


Request clarification as to the intended usage of the value "W" in EB12. Is the intent to only use W when the benefit is the same regardless if the member goes in or out of network (1 accumulator) OR when the benefit amount is the same for both in and out of network (2 accumulators)?

Here are the two scenarios:

Scenario 1
Patient has a 1000 deductible for in network and a 1000 deductible for out of network. The patient satisfied the full in network deductible and used 100 of the out of network deductible.


Scenario 2
Patient has a single 1000 deductible regardless if they see an in or out of network provider. The patient satisfied 600 of the 1000 deductible.


Is this X12 structure accurate for both scenarios?


This issue is explicitly addressed in guide 005010X279. The note on EB12 code W reads "Use code “W” - Not Applicable when benefits are the same regardless of whether they are In Plan- Network or Out of Plan-Network or a Plan-Network does not apply to the benefit." Therefore, code "W" is used when the benefit is independent of In or Out of Network. The X12 structures presented for both scenarios are accurate.
Submission 4/29/2009
Status Date 7/7/2009
Status F - Final
Primary References
Document 005010X279
Set IDEB12