Interpretation of EQ05 (Composite Diagnosis Code Pointer) in 270 (005010X279A1) to be used and corresponding HI code value to be valued. TR3 requirement is that ‘if HI (Health Care Information Codes) is present then EQ05 (Composite Diagnosis Code Pointer) is required’ and ‘if EQ05 is present then HI must be valued’. HI can have maximum 8 data elements. EQ05 can have maximum 4 component element and EQ value range from 1-8 and correspond to HI 1-8 data element. In TR3, a guideline for this code pointer is listed as ‘Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment, and as per validation software vendor this note is not enforceable as the word “corresponds to” do not clearly provides any validation that needs to be implemented
Example: IF 270 inquiry contains HI segment was HI*BK:89001~, and EQ segment at same level was EQ*MH****2~
If EQ05 was ‘2’, and there is no HI02 present in 270, then how it should be treated?
While it is not logical to point to a diagnosis code that does not exist, the guide does not impose a syntax requirement that if a pointer is used in EQ05, the corresponding diagnosis code must be populated in the HI segment.
If EQ05 is 2 and there is no HI02 present in the 270, the transaction cannot be rejected based on syntax. However, that does not preclude a receiver from imposing a business level edit that rejects the related eligibility or benefit question.