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Back  RFI # 991: 005010x279 MSG segment usages

Formal vs. Informal Help Informal Formal

Submitter

Boyle-Campbell Donna

Description

Please identify if the following examples are prohibited in 005010X279 based on the MSG segment usage requirements identified in 1.4.12 Note 2 on the 2110C and D MSG segments. The note reads:
2. Under no circumstances can an information source use the MSG segment to relay information that can be sent using codified information in existing data elements. If the need exists to use the MSG segment (....)
The examples in question are:
1. MSG*INDIVIDUAL DED IS $XXX.XX PER CARE INTERVAL FOR PLACE OF TRTMT: INPAT~
2. EB*C*IND*98***23******Y~MSG*NO DEDL APPLIES TO THIS SERVICE.~ MSG*OFFICE VISIT - PROF
3. EB*U**52~MSG*EMERGENCY MEDICAL CARE~MSG*PLEASE CONTACT 1-800-XXX-XXXX FOR BENEFIT INFORMATION.~
4. PREAUTHORIZATION IS REQUIRED. FAILURE TO OBTAIN PREAUTHORIZATION OF SERVICES WILL REDUCE BENEFITS BY 50%.

Do these MSG examples violate the usage requirement stated in 005010X279 1.4.12 2110C/D Note 2 on the MSG segment?

Submitter Assigned Keywords

MSG

Response

Several items in the example above do violate the usage requirements of the MSG segment. These items must be codified using the appropriate segments and elements. "Individual" and "Deductible" and the monetary amount must be coded using the EB01, EB02, EB03, EB06 and EB07 elements. Place of treatment must be coded using the III01 element. Identifying no deductible applies must be done using the EB07 element with a "0" (zero), Office Visit must be communicated using an EB03 of a 98 which also identifies "professional" indicated above within the MSG segment. Additionally, the place of service "Office" must be codified within the III segment. "Emergency Medical Care" must be sent by using EB03 of 52, and the contact information must be returned at the appropriate PER level. Preauthorization must be sent using EB11.
---Response continued in "Recommend"---

Recommendation

---Response continued---
The MSG segment informing the provider of the 50% reduction in benefits if a preauthorization is not approved does not violate the usage requirement.

The 4th example seems to imply that the patient's benefits would be reduced by 50 percent but it is not clear as to the financial impact to the patient. Would the patient be responsible for paying the provider the other 50 percent or is this merely a financial penalty to the provider for not obtaining authorization? The 271 response generally tries to craft the response from the patient's financial liability perspective (see section 1.4.9 Patient Responsibility in 005010X279 for additional details). If this type of message is needed, it should clearly identify the financial impact to the patient and/or provider whichever is applicable.
Submission 3/15/2010
Status Date 8/10/2010
Status F - Final
Primary References
Document 005010X279
Section1.4.12
Page322
Set ID271
Table2
Loop2100C
Segment Position2500
Segment IDMSG
Element Position01
Industry NameMessage Text
Secondary References
RFI ID 898
Document 005010X279
Section1.4.12
Page425
Set ID271
Table2
Loop2100D
Segment Position2500
Segment IDMSG
Element Position01
Industry NameMessage Text