In the 271, we need to display a subscriber who has three separate plan coverages. We have three provider tiers - PPO, Premier, and Out-of-Network. The first two are considered in-network, but the coverage under PPO is 100% while Premier is 90%. Using the EB segment, how may we report this accurately?
Example:
EB*1*FAM*35*GP*Delta•Dental•PPO~
EB*D**23**Delta•Dental•Premier***.90~
EB*C*IND*23**Delta•Dental•Premier*25~
EB*C*FAM*23**Delta•Dental•Premier*25~
EB*D**23**Delta•Dental•PPO***1~
EB*C*IND*23**Delta•Dental•PPO*25~
EB*C*FAM*23**Delta•Dental•PPO*25~
EB*D**23**Out-of-Network***.90~
EB*C*IND*23**Out-of-Network*25~
EB*C*FAM*23**Out-of-Network*25~
Is it acceptable to place the plan coverage name in each EB05 as the example shows? If not, how do we display different plan coverage?
EB05 must not be used to define the different tiers, it must only be used to identify the plan/product name which appears to be Delta Dental. When a plan type can be defined such as PPO with PR in EB04, it may be identified there (this example had GP – Group Policy). The plan name is generally only returned in the plan active coverage EB.
If the first two tiers are merely Plan Network Names, you may consider using EB12 = Y in each tier and the 2110 REF with REF01 = N6, an identifier in REF02 and the Plan Network Name in REF03 (e.g. REF*N6*1*Delta Dental PPO~, REF*N6*2*Delta Dental Premier~).
OR
If the first two tiers are not Plan Networks, identification of the first two tiers (PPO and Premier) would be accomplished with EB12 = Y and a MSG segment with the appropriate tier name in MSG01.
The Out of Network tier would be accomplished with EB12 = N.
There are a number of other issues with the example in the description.
When Co-insurance is being identified, EB01 must be A (not D as in the example) and the value in EB08 is to represent the patient’s portion of responsibility (in this case it would be .1 representing 10% for the Delta Dental Premier tier).
When Deductible is being identified, the actual base dollar amount must be identified in EB07 (this example did not have any dollar amount identified and would not be compliant with the requirements of the 005010X279 TR3). It would not be compliant merely with EB06 = 25 (Contract) as identified in the example.
The corrected example (including deductible dollar amounts represented in EB07 and the reference to contract (25) removed in EB06 and replaced it with 23 – Calendar Year)
EB*1*FAM*35*PR*Delta Dental~
EB*A**23*****.10****Y~
REF*N6*2*Delta Dental Premier~
EB*C*IND*23***23*100*****Y~
REF*N6*2*Delta Dental Premier~
EB*C*FAM*23***23*200*****Y~
REF*N6*2*Delta Dental Premier~
EB*A**23*****0.00****Y~
REF*N6*1*Delta Dental PPO~
EB*C*IND*23***23*0*****Y~
REF*N6*1*Delta Dental PPO~
EB*C*FAM*23***23*0*****Y~
REF*N6*1*Delta Dental PPO~
EB*A**23*****.10****N~
EB*C*IND*23***23*250*****N~
EB*C*FAM*23***23*500*****N~
The example had a special character in EB05 “•”. This special character is not one of the basic characters identified in Appendix B section 1.1.2.2 or extended characters identified in Appendix B Section 1.1.2.3 and would not be advised to be sent in an EDI transaction.