There are a few things to bear in mind about DDE, internet or not, vs 270/271 (or any
mandated transaction for that matter). If the health plan offers DDE, they must also
support their 270/271 to the same level as the DDE system, so long as there is a place
for the information in the 270/271. Not supporting the standard transaction to the
same level as on DDE would be considered an incentive to use DDE over the standard
transaction. 45 CFR Parts 160 and 162 (the transaction final rule) states:
"162.925(a)(4) A health plan may not offer an incentive for a health care provider to
conduct a transaction covered by this part as a transaction described under the
exception provided for in 162.923(b).
"162.923(b) Exception for direct data entry transactions. A health care provider
electing to use direct data entry offered by a health plan to conduct a transaction
for which a standard has been adopted under this part must use the applicable data
content and data condition requirements of the standard when conducting the
transaction. The health care provider is not required to use the format requirements
of the standard."
For instance, if the DDE system can identify that the subscriber has a $10 copay for a
physician office visit, they must return this information in the 271
(EB*B**98****10~). If the DDE system identifies the subscriber's Primary Care
Physician, so must the 271 (EB*L~LS*2120~NM1*P3*1*JONES*MARCUS***MD*SV*111223333~).
Most of the information that could be displayed on a DDE system would be able to be
returned in the 271 transaction.
The 271 response must also be returned as quickly as the one returned on the DDE
system (once again there cannot be an incentive to receive a faster response on DDE
over the standard transaction).
Offering an elaborate DDE system and supporting the "Yes/No" minimal response on the
271 mentioned below would not be a compliant solution.
Stuart Beaton
Vice President
Washington Publishing Company
Co-Chair X12N/TG2/WG1 - Health Care Eligibility
[EMAIL PROTECTED]
-----Original Message-----
From: David Frenkel [mailto:[EMAIL PROTECTED]]
Sent: Thu 5/30/2002 12:53 PM
To: [EMAIL PROTECTED]
Cc:
Subject: RE: Internet Transaction limitations?
Larry,
You are correct but you might ask the healthplans you may work with if
they can support anything beyond 'yes' or 'no' for eligibility on the
270/271. A yes or no response is the minimum requirement for the
270/271.
Regards,
David Frenkel
Business Development
GEFEG USA
Global Leader in Ecommerce Tools
www.gefeg.com
425-260-5030
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Thursday, May 30, 2002 9:22 AM
To: [EMAIL PROTECTED]; [EMAIL PROTECTED]
Subject: Re: Internet Transaction limitations?
Is it also true, that even if a healthplan supports a DDE type of
eligibility
system that they must ALSO support a 270/271 if that transaction is
requested
by any of their providers?
Larry A. Saltzman, MD
