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]>
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