We currently have a state mandate (CO State Mandate - House Bill 1353) that if an insured gives back incorrect eligibility information then they are prevented from taking back any monies paid in error.
Whe we have an member on an INDIVIDUAL policy in the state of Colorado who fees are not paid to date and in their grace period we would like to return an EB01=V (cannot process) or EB01= U (contact entity for eligibility and benefit information) without returning an EB01 = 1 - 8 but need to clarify this is not against the TR3.
The TR3 front matter states the following:
"For each plan for which the individual has active or inactive coverage, a 2110C/D loop is required with EB01 Status = 1, 2, 3, 4, 5, 6, 7 or 8 with 2110C/D EB03 Service Type Code = 30 (Health Benefit Plan Coverage) and Plan Name in EB05 if one exists."
In the siutaton where the member is not up to date on his fees, during his grace period, the member is NOT active or inactive.
If you have no way, at the time which the 270 transaction is received, to determine if the patient is an active member or not, then you would be compliant with the 270/271 TR3 to return only an EB01 value of ‘U’ (Contact Following Entity for Eligibility and Benefit Information), along with the applicable contact information. EB01 = ‘V’ (cannot process), would not be appropriate to use in this situation.
However, it should be noted that a major intent behind the usage of Electronic Transactions in the Healthcare industry is to reduce the volume of phone calls made to payers and to provide a useful response to a provider in a reasonable amount of time so that they can most effectively conduct business. The 271 Eligibility Response is not meant to imply a guarantee of payment or coverage and typically occurs prior to any payment being issued. Therefore, the mandate that no monies paid in error can be refunded, would only apply to the payer’s system at the point where a claim is being processed for payment, and not at the point where a 271 eligibility response has been issued.
Another option, depending on the specific wording of the state legislative mandate, would be to return a full 271 response as normal, using EB01 = 5 (Active – Pending Investigation). If it was clearly explained to the provider community that you do business with in Colorado, that EB01 = 5 indicated that in fact a claim submitted for this patient may not be paid, then it would give the providers that additional piece of information, along with other eligibility and benefit details they may need to know, in order to make an informed decision to provide care or not, without having to make expensive and time consuming phone calls.