Stuart, Thank you for your response, it is helpful however I am not finding elements that would cover some of the things we would like to convey. We administer Supplemental Medicare plans, many of which are pre-standardized. The pre-standardized policies had Rider options available where the policyholder could select none or 10 if they wanted to. Also, the riders have benefits that vary based on a schedule selected by the policyholder at the time the policy was taken. Therefore, we may have 50 policyholders with the same "Base" plan but each policyholder may have additional benefits that would be unique just to them. What we would like to return is the description of the base plan using as many of the standard elements as needed, and add a MSG segment saying "Riders attached, call for additional benefits." We also have some plans that have additional benefits due to State Mandates. An example of this would be diabetic supplies paid at 100% if not approved/paid by Medicare. I see no elements specific to diabetic supplies or state mandates and would like to return a MSG segment saying "State Mandates may allow for additional benefits, call for more information." Would appreciate your input. Thanks.
Patricia Gagliardi Tech Support Wakely & Associates 727-584-8128 x 2241 > -----Original Message----- > From: Stuart Beaton [SMTP:[EMAIL PROTECTED]] > Sent: Monday, September 30, 2002 1:12 PM > To: [EMAIL PROTECTED] > Subject: RE: 271 loop 2110C EB > > 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? > > > > > > > > **************************************************************** > > Please Note > > The information in this E-mail message is legally privileged > > and confidential information intended only for the use of the > > individual(s) named above. If you, the reader of this message, > > are not the intended recipient, you are hereby notified that > > you should not further disseminate, distribute, or forward this > > E-mail message. If you have received this E-mail in error, > > please notify the sender. 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