Martin, Perhaps someone from the dental world could confirm how "pricing query" 837-Ds are answered... but I have assumed that they are answered with an 835 using a reason code that indicates that it is only a predicted payment.
The 271 seems to be designed to carry individual eligibility concepts and values. If the provider knows the plan's adjudication rules, however, he/she could apply those rules to the elig. parameters returned in the 271, and predict the payment that way. Both processes look useful, but it may not be possible to do them both with the same transaction. -Chris At 12:17 PM 5/27/02 -0400, Martin Scholl wrote: >Chris, >to combine the eligibility query with a pricing query seems only logical and >in today's climate of depressed payments for providers and an adequate >self-defense mechanism. > Recently at my dentist, we checked the pricing before I went ahead to >have a crown made. Just to know that I have coverage does not mean much >since the insurer wanted to pay only $40 towards an $800 crown. > >But I want to come back to my question. Could EB07 be used to relay pricing? >The IG does not necessarily prohibit this and it definetely has the >necessary data fields to tell a provider what the benefit amount for a given >procedure is. > >Martin Scholl >Scholl Consulting Group, Inc. >301-924-5537 Tel >301-570-0139 Fax >[EMAIL PROTECTED] >www.SchollConsulting.com > > >----- Original Message ----- >From: "Christopher J. Feahr, OD" <[EMAIL PROTECTED]> >To: "Martin Scholl" <[EMAIL PROTECTED]>; <[EMAIL PROTECTED]> >Sent: Saturday, May 25, 2002 8:09 PM >Subject: Re: 270/271 question > > > > Martin, > > It appears that what you are proposing is more of a "pricing query" than >an > > "eligibility query", an issue that we are also facing in vision care. >Most > > vision plans are structured like retail pharmacy plans, in that a set of > > complex rules exist in virtually every case that would allow the provider > > (of eyeglasses, for example) to know ahead of time not only the patient's > > co-payment (an eligibility item), but the provider's payment and contract > > "write-off" adjustment (pricing items). I understand that the Dental 837 > > has a flag that permits its use as a "pricing query". Presumably, NCPDP > > supports this somehow for retail pharmacy. > > > > I don't believe the 837-P can be used in this manner.. can it? If not, it > > should probably be considered. > > > > -Chris > > > > At 08:45 AM 5/21/02 -0400, Martin Scholl wrote: > > >One of the most important tasks of insurance validation is to find out >how > > >much I get paid as a provider. > > >I am not sure how I can do this with the 270/271 transaction set. > > >For example: > > >A provider indicates in the EQ segment a Composite Medical Procedure > > >Modifier (HC:46735). He/She wants to charge $20,000 for this operation. > > >Where in the 270 would I indicate the proposed amount? > > > > > >Where in the 271 would I indicate how much a payer actually pays for >this? > > >EB07? > > > > > >Martin Scholl > > >Scholl Consulting Group, Inc. > > >301-924-5537 Tel > > >301-570-0139 Fax > > ><mailto:[EMAIL PROTECTED]>[EMAIL PROTECTED] > > >www.SchollConsulting.com > > > > > > > Christopher J. Feahr, OD > > http://visiondatastandard.org > > [EMAIL PROTECTED] > > Cell/Pager: 707-529-2268 > > Christopher J. Feahr, OD http://visiondatastandard.org [EMAIL PROTECTED] Cell/Pager: 707-529-2268
