We represent a few plans that have diagnostic based benefits. For example, the Office Visit service type would have different copayments depending on the reason the person is seeking service. Well Care pays with one copayment, Diabetes with another, TMJ with another, Maternity with another, Weight Loss with another, Infertility with another, etc.
We have two issues with codifying this information:
#1) Many of the 'treatment reasons' encompass a range of diagnosis codes. The HI segment is only setup for a single diagnosis per each of the 8 slots.
#2) Some of the plans have more than 8 different treatment reasons and currently the HI segment is setup on the 271 to only allow for 8 diagnosis codes.
We also have not been able to limit based on the provider as some provider specialties (like a family doctor) can treat virtually anyting.
Would this be an allowable use of the Message Segment (i.e. "This Benefit Information Applies to Treatment of Diabetes Only", etc.)?
The 005010X279A1 TR3 does not require returning co-payment amounts.
With regards to using the Message segment, Section 1.4.12 Message Segments state “Under no circumstances can an information source use the MSG segment to
relay information that can be sent using codified information in existing data elements (including combinations of multiple data elements and segments).”
Since these co-payment amounts are specific to service type codes, procedure codes or diagnosis codes, it is recommended that you support these types of inquiries in the 270 in order to give back very specific benefit related co-payments. Sending back a litany of co-payments for a more general response would not be recommended.