Missing EQ/EB descriptors for 270/271

[DrLarryS]

We are in the process of taking our payor benefit data and assigning the individual benefit and copayment information to EQ and EB buckets so that reporting to a provider can be proper.  In going through the information that our payor BA's want us to report we have found some benefits that seem to defy description.  Here are three examples:

1. Allergy injection.  Although there is a code for allergy testing (79) there is no code for regular allergy injections.  Testing is not the same as injection and there are different benefits for each.  What do we do?

2. Injections.  If a patient is given an injection in the office (examples pain shot for migraine) there is no code for injection.  This could apply to my example above as well.  Same issue.

3. Urgent care.  There are free standing urgent care facilities that are separate and apart from emergency rooms.  Health plans prefer to steer patients to urgent care centers to avoid emergency room charges.  And to make this attractive to patients the copayment for urgent care center visits are usually much less and very different than emergency copayments. I do not find a code in the EQ or the EB segments that define an urgent care copayment.  What shall we do?

Thanks for your advice.

Yours truly,
Larry A. Saltzman, MD
CEO
Insurance Benefit Spot Check, Inc.
1010 Hurley Way, Suite 180
Sacramento, CA  95825 ---
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