On some plans, patient responsibility applies only after a benefit dollar limit has been met or exceeded.
e.g., $1500 is an earmarked benefit that a member will receive for DME service only. The payer will pay up to $1500 for this benefit and after that amount is paid the member will share the cost of patient responsibility (i.e. deductible, coinsurance etc.).
So $1500 is the benefit limit that member gets and not the cost share/patient responsibility that member pays.
My attempt is as follows:
EB*1*IND*18**PLANNAME*24*0****W
EB*G*IND*18**PLANNAME*23*0****W
MSG*PATIENT RESPONSIBILIY APPLIES AFTER FIRST $1500 OF BENEFIT PAID
EB*A*IND*18**PLANNAME*23**.2***W
MSG*PATIENT RESPONSIBILIY APPLIES AFTER FIRST $1500 OF BENEFIT PAID
I would appreciate your thoughts on my attempt
The EB*1 is an attempt to indicate the amount already paid year to date for this benefit
There is currently not a value in the EB01 of the 005010X279A1 271 TR3 to specifically represent this benefit
EB*1*IND*18**PLANNAME~
EB*D*IND*18**PLANNAME*23*1500****W~
MSG*PATIENT RESPONSIBILITY APPLIES AFTER FIRST $1500 OF BENEFIT PAID~
EB*D*IND*18**PLANNAME*29*1500****W~
MSG*PATIENT RESPONSIBILITY APPLIES AFTER FIRST $1500 OF BENEFIT PAID~
EB*A*IND*18**PLANNAME*23**.2***W~
MSG*PATIENT RESPONSIBILITY APPLIES AFTER FIRST $1500 OF BENEFIT PAID~
If you have a business need not supported in a published TR3, you may submit an ASC X12 change request for consideration in a future version of the TR3. Change requests are submitted at http://changerequest.x12.org/