Be very careful in your use of the MSG segment. While your intentions may be noble,
not only does the X12N 270/271 Health Care Eligibility Benefit Inquiry Response
Version 004010 Implementation Guide discourage the use of the MSG segment in the 271,
the second note for the segment explicitly prohibits use of the MSG segment to send
information that can be codified in the other segments and elements of the transaction
(and that includes the use of Procedure codes).
For example you cannot put a message that says "Out of Network" in MSG01. That can be
codified by using EB12 = N. Likewise, you cannot duplicate information in MSG01 that
was sent elsewhere in the transaction. Another example would be a message "5 visits
per calendar year" in MSG01. That can be codified by using EB06 = 23 (Calendar Year),
EB09 = VS (visits) and EB10 = 5. Anything that can be codified by combining elements
(or even using a single element for that matter) in the transaction cannot be sent as
a free form text message. There are many ways to combine the elements in the 2110 EB
loop to get the message across without having to use free form text. The idea is to
automate the process as much as possible.
I have also seen people try to use EB05 (Plan Coverage Description) as another place
for free form text messages. EB05 is only to be used to convey the specific product
name for an insurance plan (e.g., Gold 1-2-3 Plan, Seniors Plus Plan), not the
benefits contained as a part of a plan.
Hope this helps,
Stuart Beaton
Vice President
Washington Publishing Company
Co-Chair X12N/TG2/WG1 - Health Care Eligibility Work Group
-----Original Message-----
From: Tom Drinkard [mailto:[EMAIL PROTECTED]]
Sent: Mon 9/30/2002 12:54 PM
To: [EMAIL PROTECTED]
Cc:
Subject: RE: 271 loop 2110C EB
Joan,
The answer to your questions is that there is no clear-cut answer.
For co-insurance percentages, you could list the 500 or so procedure codes in
individual EB segments.
For deductibles, many have chosen to show the deductible applying to EB03 =
35.
Most dental offices would know whether or not to apply the deductible to
preventive and diagnostic procedures. You can list separate deductible information
(and maximums) under the Service Type for Orthodontia.
The best you can do is to review the options available and choose how to
express the information you want to express. This same philosophy would apply to
specific benefits for exams, cleanings, full-mouth x-rays, etc. There is no service
type for the above benefits. Some payers have chosen to select a single procedure
code in each group and express the benefits for that code. These payers would be
implying that the benefit extends to all eligible procedures in the group.
For example, exams could be expressed as
EB*A*FAM*41*****1.00*****AD:D0120~
HSD*FL*1***34*6~
This could be interpreted as Exams are covered at 100% and limited to one
every six months.
There is free-form text available in EB05 (50 characters) and up to 10 Message
segment per EB loop, where each Message segment is up to 264 characters. I would
strongly urge you to avoid free-form text, since it will make your response
HIPAA-compliant, but non-standard. Since your response would be non-standard, it
would be less useful to automated systems for implementation. The end result would be
that there may be less usage of the automated Eligibility process.
Hope this helps.
Tom Drinkard
EDIT, Inc.
[EMAIL PROTECTED]
(678) 795-1251 (voice)
(775) 458-6117 (fax)
-----Original Message-----
From: Joan Perry [mailto:[EMAIL PROTECTED]]
Sent: Thursday, September 26, 2002 6:20 PM
To: [EMAIL PROTECTED]
Subject: 271 loop 2110C EB
When giving dental co-insurance percents for benefits, our plans are set up by
preventive, basic, major, and ortho categories. The EB03 segment in this loop does not
list these values. Instead it lists the CDT-3 categories. Unfortunately we have plans
that do not follow these completely. For example, our plans list some CDT-3
Periodontic services as basic and others as major. I am looking for suggestions on how
to respond on the 271 for these.
Also, how do you report a deductible that applies to basic and major only?
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