Section title: Requests for Interpretation
Returning Benefits When Exclusions Exist Prior to Dollar Limit Application

What is the correct way to return benefits on the 271 when there are exclusions for specific services prior to a benefit such as an annual dollar limit kicks in?

RFI Response

It is difficult to convey the scenario provided in a codifiable manner without the use of the MSG.  As long as the MSG is not used instead of providing the information in a codifiable way, the response may include a combination of EB, HSD and MSG segments to address the business needs.

RFI Recommendation

There is a service type code benefit, e.g., chiropractic services, which excludes the first visit and associated x-rays from the per year benefit dollar limit starts to be applied.  For example, the per year benefit dollar is $1000.  The charges for the first visit and associated x-rays will not count towards the benefit dollar limit.  When the second visit or additional services other than the first visit and associated x-rays occur, the per year limit of $1000 will start to have those services applied against it.
We recommend the following to indicate the benefit dollar limit and the exclusion from it based on the subsequent information provided.
To indicate the benefit limitation, the following EB, HSD and MSG segment examples are recommended to indicate the limitation of a $1000 per calendar year (this could change depending on whether the information source’s limitation is based on service year or calendar year; we used calendar year for example purposes only), the included services types (again, those used below are for example purposes only) that the $1000 calendar year limitation applies to, the services delivery pattern for every 1 visit exceeding 1, and we further identified the first visit exclusion, and subsequent visit limitation applicability by using the MSG segment.


MSG*Services provided during every visit after the first visit are applicable to the calendar year financial limitation~