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Back  RFI # 881: OOP Response Formatting

Formal vs. Informal Help Informal Formal


carlmel mcdonald


OOP Response Formatting when certain services do not have applicable OOP.

A benefit plan has an OOP/Stop Loss, for most services, of $1000 per calendar year, and 80% coinsurance. Mental Health benefits are paid at 80%, however the patient's 20% portion for these services does not count toward the OOP $1000 max.
Also, once the OOP calendar year max is met, the Mental Health benefits are still paid at 80%. So they are essentially totally excluded from the entire OOP benefit.

How do you suggest this should be coded?

A few options were discussed:
1) Return OOP at the universal level with a msg segment indicating that OOP does not apply to certain service type such as Mental Health.
2) Return OOP at the service type level and omit for services where OOP does not apply.
3) Return OOP at the service type level with 0 for services where OOP does not apply

Submitter Assigned Keywords

OOP Formatting


The Out of Pocket (Stop Loss) amount (OOP) represents the maximum a patient is responsible for paying out of their own pocket before a benefit is covered 100% (See Section 1.4.9 for full definition) and is identified using 2110C/D EB01 = G and patient’s maximum OOP amount is sent in the same segment in EB07. OOP amount is generally used at a plan level or in some cases at a service type code level when an OOP amount does not apply at a plan level.

There is no codified method for identifying services not included in the OOP amount. The simplest solution would be option 1, identifying service types that have no Out of Pocket maximum with a MSG*Does not apply to Out of Pocket Maximum~.

Option 2 would not be appropriate, as returning multiple service type codes with an OOP maximum would be interpreted as each service type having their own separate OOP maximum.

Option 3 would not be appropriate as an OOP of $0 would represent the maximum OOP for the service is $0 (the patient owes nothing).


It is highly recommended that the health plan also return the amount remaining for the Out of Pocket amount. Like all patient financial responsibility amounts, the remaining amount the patient is responsible for is much more important to the provider and patient than initial amount.

The remaining amount for Out Of Pocket would be returned as follows:

EB*G**30**GOLD 123*29*75~

This represents the patient's Out Of Pocket amount for the Health Benefit Plan Coverage in the Gold 123 plan remaining amount is $75.

The Work Group will explore data maintenance to find a codified solution.
Submission 10/8/2009
Status Date 2/26/2010
Status F - Final
Primary References
Document 005010X279
Set ID271