Broad question is, when should EB01 values of "R", "U", and "W" be used?
More narrow question exists around single data source with data for multiple payers. An eligibilty request is received and the patient is identified within the data (by ID, DOB, and name).
If patient is covered by requested payer AND another payer, how should the other payer be identified?
If patient is NOT covered by requested payer, but is covered by another payer, how should the other payer be identified?
TR3 005010X279 Section 1.4.7.1 271 requires that if an Information Source locates a person in their system (the Information Source’s system), they must either identify the person’s coverage in EB01 with values 1 through 5 if they have active coverage, values 6 through 8 if they have inactive coverage.
EB01 code value “U” (Contact Following Entity for Eligibility or Benefit Information) is used to identify the true source of the patient’s eligibility status or benefits. This code is typically used when the Information Source identified in Loop 2000A is acting as the claim processor for a plan sponsor such as a Labor Fund, however the plan sponsor, not the Information Source, makes the final determination of when a person is active or inactive.
EB01 code value “R” (Other or Additional Payer) is used to identify that the patient may have coverage from a payer in addition to the Information Source identified in Loop 2000A. The identity of this payer is included in the 2120 loop when the EB01 value is “R”. Coverage status and benefit information for this payer is prohibited from being sent by the Information Source as noted in Section 1.4.7.1 271 item 6.
EB01 code value “W” (Other Source of Data) would only be used in when the Information Source wishes to identify where the Information Receiver can obtain additional information not required by 005010X279 and not already included in the 271 response. EB01 code value “W” cannot be used when either code value “R”, “U” or any of the other EB01 code values is more appropriate.
If patient is covered by requested payer AND another payer, an Information Source would be required to identify coverage status in the Information Source’s plan with an EB01 with values 1 through 5 (Active Coverage) and to identify coverage for another payer with another 2110 loop EB01 with a value of R (Other or Additional Payer) with the identity of the other payer in the 2120 loop.
If patient is NOT covered by requested payer, but is covered by another payer, an Information Source would be required to identify the coverage status in the Information Source’s plan with an EB01 with values 6 through 8 (Inactive coverage) and to identify coverage for another payer with with another 2110 loop EB01 with a value of R (Other or Additional Payer) with the identity of the other payer in the 2120 loop.
Prior Related RFIs 1787