Hi,
I am not yet on the specific 270/271 listserv, so sending this question to
you all.
Here's what I hope is an understandable scenario with ultimate question.
Phil sends an X270 transaction to Pacificare.
The transmission contains an Information Source loop (with one and only one
entry) indicating that the source of the required information is Pacificare.
The transmission contains an Information Receiver loop (which refers back to
Phil himself using an ID with a qualifier indicating whether it is a
National Provider Id, Employer Identification Number, SSN, Payor assigned ID
Number, Pharmacy Processor Number, Service Provider Number or HCFA Provider
ID Number)
Phil wants to know if Deb has coverage for Acupuncture based on a specific
diagnosis code
Phil adds an entry for Deb into an X270 transmission
At the level of the Subscriber Information Loop Phil put in a Hierarchical
Child Code of (0) to indicate there will be no subordinates. Phil also puts
in a unique Trace Number so that when he gets back a response he'll be able
to definitely identify that it is a response to this request. Then he puts
in Deb's information to include Deb's ssn for identification purposes. SSN
used to identify Deb as the primary subscriber for this transaction. Also
recognized (based on the Hierarchy code of zero) that Deb is the patient in
question for this transaction. Since Phil is also the submitting provider
for this transaction he does not fill in the Provider info in the Subscriber
Loop. When Phil gets to the Subscriber Eligibility or Benefit information
Loop he can now ask as many questions (specific to Debs coverage) as he
likes. What Phil wants to know is whether Deb is covered for this particular
therapy so he submits a Service Type Code of "64". For the Coverage Level
Code he submits "IND" to indicate he is looking for individual coverage info
for Deb. For Insurance Type Code he submits the information he has for what
Insurance type Deb has. In Subscriber Benefit or Eligibility Addtl Info Phil
indicates that he wants to know about this benefit in relation to a specific
diagnosis.
The transaction sent by Phil is received by Pacificare. It is recognized
that this Xaction is a 270 and handled as such. It recognizes that the
provider wants to know if Deb has active coverage for a specific benefit for
a specific diagnosis. If the benefit is not defined at this specific level,
is it correct to reply to the benefit level of acupuncture (without
reference to diagnosis, since that info doesn't exist) or is it correct to
answer to the level of a generic benefit request of Service Type Code =
"30". Receiver originally submitted by Phil a subscriber loop with the
information he provided, including his trace number, and a Request
Validation Segment indicating that he does not have authorization to access
this information (Reject Reason Code = "50") and that he should not respond
(Follow up Action Code = "N")
your help is appreciated!
Connie
<<...OLE_Obj...>>
Connie Lagneaux, RN, BSN, MBA
Senior Business Analyst
5151 E. Broadway Boulevard, suite 1050
Tucson, AZ 85711
Phone (520) 571-1988 ext. 153
Fax (520) 571-1927
<mailto:[EMAIL PROTECTED]>
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