Section title: Requests for Interpretation
RFI #
2485
EDI 270/271 Non-Covered Benefits - section 1.4.7.1, rule# 8
Description

As per, EDI 270/271 (ASC X12N/005010X279) implementation guide, section 1.4.7.1, rule# 8 for STC30 response states “If it is not a covered benefit, the code must NOT be returned”.

Question:
• Does above rule only apply when the service type is a completely a non-covered. i.e., non-covered benefit for both in-network (INN) and out of network provider (OON)?
• OR also apply when a service type is a covered benefit for in-network provider and non-covered for out of network provider?

If the rule also applies in the latter case, then what would be expected response?

• Should we return only covered benefit for INN provider and omit non-covered line (EB01 = I) for OON provider?
• Or return both covered benefit for INN provider and non-covered line (EB01 = I) for OON provider?

RFI Response

Based on your example and explanation above, the front matter section 1.4.7.1, Item 2, 8 and 9 would address your needs.
The following example shows the request and responses that would apply to the business scenario explained:
EQ*30~
1.4.7.1 #2. EB*1**30*HM~
1.4.7.1 #8. EB*1**33*HM********Y~
EQ*33~
1.4.7.1 #2. EB*1**30*HM~
1.4.7.1 #9. EB*3**33*HM********Y~
1.4.7.1 #9. EB*I**33*HM********N~
EB*B**33*HM**26*25*****Y~
The response to include an EB01 = I when the EQ01 = 30 would not be appropriate as Item #8 specifies that only EB01 = 1-5 is allowed to be returned when it’s a covered benefit at a plan.

NOTE: The EB01 of “3” and “I” were used as examples to provide visual clarity.

DOCUMENT ID
005010X279