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Back  RFI # 845: 271, Passing Member Deductible

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Submitter

karthik Subramanian

Description

What is the intent of 5010, TR3 in regards to passing Deductible information. With the EB03 now allowing for mulitple service types to be reported on the same line, is it the intent of 5010 to pass Deductible at the Service type level or should Payers continue to return Deductible at the General (30) benefit Level?

Response

In principle, there are no differences in how the deductible is returned in the 5010 as it was in the 4010A1 with the exception that a value must be returned in EB07 for 5010 271s.

The use of the repetition function of EB03 is required if multiple 2110 loops occur and the only difference between them is the Service Type Code (STC). This would apply to any 2110 loop, including but not limited to Deductible.

When Deductible information is reported, it can be reported at both the plan level or the STC level, if a separate deductible applies to the STC and is not already included in the plan deductible.

Recommendation

There are no requirements to return deductible amounts (plan or STC) in the 5010 TR3, however returning this information is highly recommended. There also is no requirement to include EB03 = 30 to indicate that the deductible being reported is for the plan, however it is recommended (absence of an STC would imply the plan deductible).

It is not the intent of the 271 to identify the sub-components of the plan deductible, only items that would not be included in the plan deductible should be reported.

Use of the repetition function of EB03 would only be used if the deductible amount across multiple STCs are co-incidentally the same amount, and the deductibles are to be viewed as separate deductibles. The repetition function of EB03 is not to be used to identify sub-components of a common deductible, in that case, a higher level STC should be used.
Submission 8/27/2009
Status Date 10/5/2009
Status F - Final
Primary References
Document 005010X279
Section2
Page291
Set ID271
Table2
Loop2110C
Segment IDEB