How do we represent the Physician Visit – Office (BY&BZ) Copays when we have a different Copay for PCP versus Specialist Office visits. This is not their assigned PCP, but a provider who is a PCP Type provider – General Practice, DO, Internal Medicine….vs a Specialist – Cardiologist, etc.
Here are a few examples:
Example1-the PCP Copay is $30, Specialist is $50
Example2-The PCP is $10 copay, Specialist with a referral is $20 Copay Specialist without referral the Copay is $50
Example3-Ties the PCP/Specialist Differential also in with the Network Tiers:
• The PCP is $20 copay for Tier 1, $35 Copay for Tier 2 then 70/30 after deductible, OON $45 Copay then 50/50 after deductible
• The Specialist is:
• With referral is $30 copay for Tier 1, $40 Copay for Tier 2 then 70/30 after deductible, OON $50 Copay then 50/50 after deductible
• Without referral is $40 copay for Tier 1, $50 Copay for Tier 2 then 70/30 after deductible, OON $50 Copay then 50/50 after deductible
There are a number of concepts associated with co-payments in this RFI, each concept is addressed individually.
Co-Payment
Co-payment information is identified in EB07 with “B” in EB01. For example if the patient’s co-payment is $10, the value in EB07 would be “10”.
Specialist
The 005010X279 and associated errata allow for the use of the MSG segment when items cannot be codified elsewhere in the response. There is no codified solution to identify “Specialist” so you may include “Specialist” in the 2110 MSG01 for the 2110 loop with the co-payment information codified appropriately.
Referral
There is no codified solution to report the requirement of a referral in the 005010X279 and associated errata. Therefore, the 2110 MSG01 can be used to codify the difference in Co-pay with and without a referral. If the referral is considered to be an authorization or certification, then to indicate a co-payment with an authorization or certification, place Y in EB11 with the co-payment information codified appropriately. To indicate a co-payment without an authorization or certification, place “N” in EB11 with the co-payment information codified appropriately. I or Out of Network. When benefits differ In Network or Out of Network, use EB12, with Y to indicate In Network, N to indicate Out of Network.
Tiers
There is no codified solution to indicate multiple Tiers that apply In Network, so you may indicate the appropriate Tier in the MSG segment. This may be combined with the “Specialist” MSG if applicable.
Co-Insurance
The patient’s portion of Co-Insurance responsibility is reported in EB08 with EB01 = “A”. If the patient’s co-insurance percentage is 30 %, the value in EB08 would be “.3”, if it were 50% the value in EB08 would be “.5”. Co-insurance generally applies after deductible has been met and does not need to be indicated though a message in MSG01 such as “After deductible has been met” would be allowable.
All of these items may be used together as appropriate to form the 2110 loops identified in your examples.