I'd like to offer a couple of friendly amendments to Laurance's approaches.
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. > Use of ZZ would be highly discouraged, as you are likely going to find yourself in conflict with the mandated code source for procedure codes - HCPCS level 1 and 2. Recommend use of HC for EB13-1. I believe there is a HCPCS code for Allergy Injection. The Eligibility work group has wrestled with the Allergy Injection issue in the past (it was a DSMO request that was denied). We do not want to get into the business of adding Service Type Codes when there are equivalent HCPCS codes. 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" > There is no requirement to have a value in EB03 (assuming you have already established they have active coverage in another 2110 EB). Use whatever appropriate value you need for EB01 then place "Urgent Care" in MSG01. Getting "close" in EB03 may do more harm than good. 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). > Again, there is no need to get close with EB03, and I agree, you should hate the use of EB05, as it is not designed for benefit descriptions, rather plan brand names. We are clarifying the note on EB05 for the next version of the 270/271 Implementation Guide to state "This element is to be used only to convey the specific product name or special program name for an insurance plan. For example, if a plan has a brand name, such as "Gold 1-2-3", the name may be placed in this element. This element must not to be used to give benefit details of a plan." Hope this helps. Kindest regards, Stuart Beaton Vice President Washington Publishing Company Co-chair X12N/TG2/WG1 Health Care Eligibility -----Original Message----- From: Laurance Stuntz [mailto:[EMAIL PROTECTED] Sent: Wednesday, March 05, 2003 9:46 PM To: WEDI SNIP Transactions Workgroup List Subject: Re: Missing EQ/EB descriptors for 270/271 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 --- 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
