Connie, The information source is obligated to return the information it used to determine the response. According to your elaborate request, the information source determined that Deb was eligibile for accupunture (EQ01 service type = 64), but ignored the diagnosis. The information source has a couple of options. 1. Respond that the subsriber has limitations for service type 64. Use any of the other elements and segments in the 2110 loop, such as specific diagnosis codes (even if it replicates the one sent in) to identify the limitations. This would be the recommended response, especially since the information source can process elaborate requests to a certain degree. 2. Respond with the generic response (Active coverage, service type 30). While this would be a compliant response, it does little to answer the provider's question (and prevent him from picking up the phone and calling the information source - the true desired result), since apparently the system is elaborate enough to get close to the appropriate answer. The information source should not respond that the subsriber has active coverage for service type 64. This would be misleading since apparently this benefit is covered if certain conditions apply Since the diagnosis is the condition that makes the determination and was ignored by the system it could not return it to give a clear answer. Use of the code 50 in 2100B AAA03 would indicate that the Information Receiver identified in 2100B (in this case Phil) was not eligibile to do any eligibility inquiries, not that the information source cannot process elaborate eligibility requests. Hope this helps, Stuart Beaton Vice President Washington Publishing Company Co-Chair X12N/TG2/WG1 - Health Care Eligibility -----Original Message----- From: Connie Lagneaux [mailto:[EMAIL PROTECTED]] Sent: Thu 4/11/2002 3:54 PM To: '[EMAIL PROTECTED]' Cc: Subject: 270/271 question 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]> ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request. ====================================================== The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited. 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