We are a health plan with a product that has the following prescription benefit:
The greater of a $10/$25/$50 copay or 30% per prescription
We are having difficulties coding the eligibility response without using a message to indicate the benefit is per prescription and that is it the greater of the copay or coinsurance amount.
Is there a way to return a clear response without using a message?
If use of the elements and segments in the 2110 loop cannot sufficiently indicate which financial responsibility applies, use of the MSG would be appropriate.
If the co-payment amounts can be associated with a service type code, the service type code must be used in EB03.
Some of the available service type codes are:
88 Pharmacy
89 Free Standing Prescription Drug
90 Mail Order Prescription Drug
91 Brand Name Prescription Drug
92 Generic Prescription Drug
BW Mail Order Prescription Drug: Brand Name
BX Mail Order Prescription Drug: Generic
GF Generic Prescription Drug - Formulary
GN Generic Prescription Drug - Non-Formulary
An example response would be:
EB*B**GF****10~
MSG*The greater of the Coinsurance or Co-Payment applies~
EB*A**GF*****.3~
MSG*The greater of the Coinsurance or Co-Payment applies~
EB*B**GN****25~
MSG*The greater of the Coinsurance or Co-Payment applies~
EB*A**GN*****.3~
MSG*The greater of the Coinsurance or Co-Payment applies~
EB*B**91****50~
MSG*The greater of the Coinsurance or Co-Payment applies~
EB*A**91*****.3~
MSG*The greater of the Coinsurance or Co-Payment applies~
If an applicable service type code is not available, you must still identify the co-payment and co-insurance values in the EB segment and describe the conditions in the message segment.
If the message segment is used to relay this information, the verbiage needs to be the same across all related loops.
Section 1.4.12 Message Segments of the 005010X279A1 TR3 as modified by the errata explicitly states:
“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). Information that has been provided in codified form in other segments or elements elsewhere in the 271 for the individual must not be repeated in the MSG segment. If the information cannot be codified, then cautionary use of the MSG segment is allowed as a short term solution. It is highly recommended that the entity needing to use the MSG segment approach X12N with data maintenance to solve the long term business need, so the use of the MSG segment can be avoided for that issue.”
Please submit a complete change request with business requirements to ASC X12.