Chris is correct that a dental predetermination of benefits is answered using an 835, not a 271.
Jan Root. "Christopher J. Feahr, OD" wrote: > 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
