There's good news and bad news.
Bad news first: There is no way to codify the three types of benefits
you're talking about with the EB03 (service type code)
Ok news - you can likely do the Injection piece with the EB13, i.e. define
the actual procedure and tell them what the copay/deductible/etc. is
Good news - in the draft 4050 guide, at least there are service type codes
for Urgent Care and Allergy (though not specifically Allergy Injection).
Ok news - you can request additions to that list through your friendly DSMO
(and participate in their discussions if you want to influence them).
To get around the current limitations I've seen three approaches used -
listed in my order of preference
Approach 1: Work with your major trading partners to define a set of codes
to put into the EB13, with EB13-1 = ZZ and appropriate values in the
EB13-2, 3, 4 etc.
Approach 2: Get close with the EB03, and then put in a MSG segment to
define what you really mean, e.g. send two EB segments with EB03 =
Emergency, and then for the Urgent one, add an MSG segment with "Urgent
Care"
Approach 3: Get close with the EB03, and then put the description in the
EB05 (personally I really hate this one, because the description of the
EB05 is "Use this free-form text area to convey the specific product name
for an insurance plan" - doesn't sound like a benefit description to me).
WEDI folks - is there an "approved" approach that folks are coalescing
around?
Regards,
Laurance
[EMAIL PROTECTED]
To: "WEDI SNIP Transactions
Workgroup List" <[EMAIL PROTECTED]>
03/05/2003 07:05 cc:
PM Subject: Missing EQ/EB descriptors for
270/271
Please respond to
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 ---
The WEDI SNIP listserv to which you are subscribed is not moderated. The
discussions on this listserv therefore represent the views of the
individual participants, and do not necessarily represent the views of the
WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official
opinion, post your question to the WEDI SNIP Issues Database at
http://snip.wedi.org/tracking/. These listservs should not be used for
commercial marketing purposes or discussion of specific vendor products and
services. They also are not intended to be used as a forum for personal
disagreements or unprofessional communication at any time.
You are currently subscribed to wedi-transactions as: [EMAIL PROTECTED]
To unsubscribe from this list, go to the Subscribe/Unsubscribe form at
http://subscribe.wedi.org or send a blank email to
[EMAIL PROTECTED]
If you need to unsubscribe but your current email address is not the same
as the address subscribed to the list, please use the Subscribe/Unsubscribe
form at http://subscribe.wedi.org
---
The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions
on this listserv therefore represent the views of the individual participants, and do
not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If
you wish to receive an official opinion, post your question to the WEDI SNIP Issues
Database at http://snip.wedi.org/tracking/. These listservs should not be used for
commercial marketing purposes or discussion of specific vendor products and services.
They also are not intended to be used as a forum for personal disagreements or
unprofessional communication at any time.
You are currently subscribed to wedi-transactions as: [EMAIL PROTECTED]
To unsubscribe from this list, go to the Subscribe/Unsubscribe form at
http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED]
If you need to unsubscribe but your current email address is not the same as the
address subscribed to the list, please use the Subscribe/Unsubscribe form at
http://subscribe.wedi.org
