Patrice,
I think that you have provided another example of either a weakness of the
270/271 or a misconception of its proper use.
As of version 4030, there is no value for DE 1365 (Service Type Code) that
signifies Urgent Care. Thus, there is no convenient way to express the
benefit (or define the co-payment). I can't speak for the Institutional
world (or the Professional world), but in the Dental Insurance arena, there
are also many examples of where the specific benefit cannot be expressed. I
suspect the reason for this is that the Service Types reflect the categories
of Dental procedures as defined by the dental practitioners, not as defined
by the health plans.
So, is this a flaw in the 270/271, or is it a misconception of how to use
the transaction(s)? I used to think that the Service Types should align
with the categories as defined by the practitioners. After all, they're the
ones making the Eligibility Request. Now I'm not so sure.
For example, a common Dental benefit is to cover one full mouth x-ray every
36 months (or two per 60 months, or ...)
The full mouth x-ray provision usually applies to two different procedures
(Code D0210 - full mouth x-ray and code D0330 - panoramic x-ray).
There is no way to express this benefit in the 270/271.
The dentist could inquire about the specific procedure code (either D0210 or
D0330), and the health plan could respond accordingly if they choose to do
so.
Another common occurrence in Dental insurance is to provide benefits across
four "categories" of procedures. These categories are usually presented as
Preventive (usually including Diagnostic), Basic Restorative, Major
Restorative and Orthodontia. There are no service types for these
categories, either, so there is no direct way to ask or answer about the
coverage.
I have seen some health plans that attempt to work around this by including
a specific procedure code in the EB segment and explanatory text in the Plan
Coverage Description field (EB05). This is not a very satisfactory
solution, but it's all that we have (as far as I know).
I'd appreciate any and all guidance that anyone could provide so that we all
can better understand the proper use and capabilities of the 270/271
transactions.
Tom Drinkard
EDIT
(678) 795-1251 (voice)
(678) 795-1575 (fax)
[EMAIL PROTECTED]
-----Original Message-----
From: Thaler, Patrice M [mailto:[EMAIL PROTECTED]]
Sent: Wednesday, September 19, 2001 1:21 PM
To: [EMAIL PROTECTED]
Cc: Don Bechtel (E-mail)
Subject: 270-271 Question
I can not figure out how a health plan would identify an urgent care
co-pay in the 271 with the EB segment. This co-pay is different than a
ER co-pay. The health plan member might have a $30.00 urgent care co-pay
and a $75.00 ER co-pay.
Does anyone have suggestions on how to map this?
Patrice Thaler
Allina Health System
HIPAA Project
phone: 612-775-9705
pager: 612-654-3066
fax: 612-775-9715
>
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