Please explain how to relay tiered benefits on the 271 when all the documentation shows is In network and Out of network benefit levels.
For example: Gold Plan has the following tiers and benefit levels:
Tier 1 Deductible 500 OOP 1000 benefits then member has 0 responsibility (plan pays 100%)
Tier 2 Deductible 800 OOP 1600 benefits then member has 20% responsibility (plan pays 80%)
Tier 3 (Wrap) Deductible 2000 OOP 4000 benefits then member has 50% responsibility (plan pays 50%)
Out of network Deductible 3000 OOP 6000 benefits then member has 60% responsibility (plan pays 40%)
Additional Information sent in by the submitter:
We administer Self funded plans which have numerous tiers with different benefits, even within the tiers. There is more than one In Network set of benefits, there can be many network levels (Tiers).
In the case referenced below, the Tier 1 with $500 Ded and OOP 500 has a member responsibility of 0 (plan Pays 100%) except for a few benefits (like DME or Infertility) which may have a 50% coinsurance.
Tier 2 then has an entirely different Ded and OOP and Coinsurance
Tier 3 (wrap) again different
Tier 4 (or Out of Network) has again different values.
We do also have benefits where the Deductible applies to the OOP.
To make if more complicated, there are times when the different tier values are then allowed to satisfy each other.
The ASC X12 005010X279 guide does not address tiered benefits, therefore, in some cases, MSG segments are necessary in order to clearly specify this level of benefit detail in a 271 transaction. However, any portion of the information being returned that can be codified in the response, should be done so appropriately.
A way to return the given benefit scenario reflected within a 271 response is as follows:
In Network Tier 1 - $500 annual deductible ($350 remaining), no additional member responsibility, except for 50% coins for DME and Infertility
EB*C*IND*30**GoldPlan*23*500*****Y~
REF*N6*123*Tier 1~ (REF02 = ID assigned to the network represented by tier 1, REF03 = network name or description of tier 1)
DTP*292*RD8*20130101-20131231~
EB*C*IND*30**GoldPlan*29*350*****Y~
REF*N6*123*Tier 1~ (REF02 = ID assigned to the network represented by tier 1, REF03 = network name or description of tier 1)
DTP*292*RD8*20130101-20131231~
EB*A**12^83** GoldPlan*26**.5*****Y~
REF*N6*123*Tier1~ (REF02 = ID assigned to the network represented by tier 1, REF03 = network name or description of tier 1)
MSG*after deductible has been met~
In Network Tier 2 - $800 annual deductible ($250 remaining), then 20% coinsurance with $1600 OOP max ($1050 remaining)
EB*C*IND*30**GoldPlan*23*800*****Y~
REF*N6*456*Tier 2~ (REF02 = ID assigned to the network represented by tier 2, REF03 = network name or description of tier 2)
DTP*292*RD8*20130101-20131231~
EB*C*IND*30**GoldPlan*29*250*****Y~
REF*N6*456*Tier 2~ (REF02 = ID assigned to the network represented by tier 2, REF03 = network name or description of tier 2)
DTP*292*RD8*20130101-20131231~
EB*A**30** GoldPlan*26**.2*****Y~
REF*N6*456*Tier2~ (REF02 = ID assigned to the network represented by tier 2, REF03 = network name or description of tier 2)
MSG*after deductible has been met~
EB*G*IND*30**GoldPlan*23*1600*****Y~
REF*N6*456*Tier 2~ (REF02 = ID assigned to the network represented by tier 2, REF03 = network name or description of tier 2)
DTP*292*RD8*20130101-20131231~
EB*G*IND*30**GoldPlan*29*1050*****Y~
REF*N6*456*Tier 2~ (REF02 = ID assigned to the network represented by tier 2, REF03 = network name or description of tier 2)
DTP*292*RD8*20130101-20131231~
In Network Tier 3 - $2000 annual deductible ($2000 remaining), then 50% coinsurance with $4000 OOP max ($4000 remaining)
EB*C*IND*30**GoldPlan*23*2000*****Y~
REF*N6*789*Tier 3~ (REF02 = ID assigned to the network represented by tier 3, REF03 = network name or description of tier 3)
DTP*292*RD8*20130101-20131231~
EB*C*IND*30**GoldPlan*29*2000*****Y~
REF*N6*789*Tier 3~ (REF02 = ID assigned to the network represented by tier 3, REF03 = network name or description of tier 3)
DTP*292*RD8*20130101-20131231~
EB*A**30** GoldPlan*26**.5*****Y~
REF*N6*456*Tier3~ (REF02 = ID assigned to the network represented by tier 3, REF03 = network name or description of tier 3)
MSG*after deductible has been met~
EB*G*IND*30**GoldPlan*23*4000*****Y~
REF*N6*456*Tier 3~ (REF02 = ID assigned to the network represented by tier 3, REF03 = network name or description of tier 3)
DTP*292*RD8*20130101-20131231~
EB*G*IND*30**GoldPlan*29*4000*****Y~
REF*N6*456*Tier 3~ (REF02 = ID assigned to the network represented by tier 3, REF03 = network name or description of tier 3)
DTP*292*RD8*20130101-20131231~
Out of Network - $3000 annual deductible ($0 remaining), then 60% coinsurance with $6000 OOP max ($2000 remaining)
EB*C*IND*30**GoldPlan*23*3000*****N~
DTP*292*RD8*20130101-20131231~
EB*C*IND*30**GoldPlan*29*0*****N~
DTP*292*RD8*20130101-20131231~
EB*A**30** GoldPlan*26**.6*****N~
MSG*after deductible has been met~
EB*G*IND*30**GoldPlan*23*6000*****N~
DTP*292*RD8*20130101-20131231~
EB*G*IND*30**GoldPlan*29*2000*****N~
DTP*292*RD8*20130101-20131231~
This response is assuming that the deductible amount does apply to the OOP for the year. If it does not, which you suggest is how some of your plans are set up, then you would need to include the referenced MSG segment “MSG*after deductible has been met~” within each of the OOP EB loops.
If the various tier values can apply to each other’s deductible, then additional MSG segments would be required at this time referencing that. However, that calculation would be more appropriately performed by the payer on any already paid deductible monies, to ensure that accurate remaining deductible amounts are being reported.
The X12 Health Care Insurance Eligibility Workgroup is currently working on drafting business requirements for a CR to address necessary changes to the 270/271 transactions to support a consistent, codified, option for reporting tiered benefits. In order to ensure that all of your business needs are addressed in this effort, the workgroup requests that your organization submit a new change request to X12 containing specific business examples and documentation.