I don't disagree with Don's response in concept, but I think some of the wording could be misleading. Based on our interpretation of the 270/271 transactions, we see it in general as being able to be driven down to what ever level of detail the sender and responder are capable of addressing or desire to address. The question can be "does this person have coverage?" and the answer can be yes or no. The question can be "does this person have coverage for this dependant for this procedure based on this diagnosis and for what amount?" and the answer can be yes this person has coverage. Or the answer could be yes this person has coverage for this dependant. Or yes this procedure for this dependant will be covered for $x with a $y co-pay.
The level that the question or answer go to are entirely up to the individual organizations. Some key factors in deciding what level of detail to attempt are capability (can my system properly address this level of inquiry) and desire (do we want to attempt answering at that level). The ideal situation, and where this all needs to lead one day, are that the electronic question and response replace the need for manual intervention such as the phone call. However, if you are responding 100% by phone now and your system couldn't come close to responding automatically, you are not required to make the modifications to fully support it (even if you know your response will result in a phone call). As well, if your policy is you will not respond with more than a certain level of detail (will not quote $, for example) then you are not required to change that policy. As your organization assesses what they are capable of today, what it would take to move to supporting automated inquiries/responses, to what level they would want to support them, and then factor in the potential cost savings by removing/reducing the manual intervention, there may be a case to make the extra effort to do it.
Mike Augustine
Principal, SILC, Incorporated
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Wednesday, January 30, 2002 5:37 PM
To: [EMAIL PROTECTED]
Subject: Re: questions on 270/271
Health plans can respond with the information they feel is appropriate to
the inquiry, following the rules of required and situational data as
defined in the Implementation Guide. Health Plans at this time are not
being required to support diagnosis related inquiries, if that is beyond
their capabilities. However, Health Plans are encouraged to provide as
much information as they can related to the question, with the objective
being to eliminate the phone call. So, if a Health Plan knows that they
will need to answer questions to a certain level of detail on the phone,
they should provide the same level of information in their 271 response.
"Sood, Rajiv" <[EMAIL PROTECTED]> on 01/30/2002 01:56:23 PM
Please respond to <[EMAIL PROTECTED]>
To: "'[EMAIL PROTECTED]'" <[EMAIL PROTECTED]>
cc:
Subject: questions on 270/271
Good Afternoon,
I would like to ask a few questions regarding the 270/271:
1. In the 270/271 arena, what is the definition of "free-standing" (code
89)
(EQ01) (page 93 for 270 and 301 for the 271).
2. How could plans handle providing 3-tier pharmacy benefit information ?
3. If the 271 minimum response is a simple "yes/no" the person is (or is
not) eligible, and a plan decides to provide more information (i.e., a true
271), is this an all or nothing proposition ? i.e., if the plan decides to
provide a true 271, must all the "required" and "situational" info be
provided or is there some choice if a plans systems cannot support
inquiries
by certain criteria (like diagnosis for example).
Thanks
Rajiv
Thank you,
Rajiv Sood, MBA
HIPAA Implementation Manager
Oxford Health Plans
48 Monroe Turnpike, Trumbull CT 06611
External Phone: 1-203-459-6913
Internal Phone: 8-204-6913
Fax: 1-203-459-6464
Email: [EMAIL PROTECTED]
Toll Free: 1-800-889-7658 Ext. 6913
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