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Back  RFI # 813: Out Of Pocket waiver

Formal vs. Informal Help Informal Formal


karthik Subramanian


If a serivce type is excluded from OOP what should a Plan pass back on the response (271). A Plan is suggesting that a Zero (0) should be passed back when it is excluded for a service type, is it correct?


This issue is explicitly addressed in guide 005010X279. Section 1.4.9-G states on page 35 "The Out of Pocket (Stop Loss) amount is represented as a dollar amount in EB07. If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in EB07." Page 33 also states "For each of the EB01 code values that represent either a dollar or percentage based patient responsibility, codes and their definitions have been identified and instructions on how to use them in conjunction with this Implementation Guide are included below."

Out of Pocket (Stop Loss) is identified by placing “G” in EB01 and the dollar amount in EB07. The Situational Rule for EB07 states “Required when EB01 = B, C, G, J or Y.”

The Plan's statement that a zero "should be passed back" is in error. For this situation, a zero MUST be passed back per the instructions in the guide.
Submission 7/17/2009
Status Date 7/28/2009
Status F - Final
Primary References
Document 005010X279
Set ID271