Section title: Requests for Interpretation
RFI #
2301
271 / Multiple Copay/Coinsurance
Description

We have a current plan with multiple different copayment/coinsurance amounts for the same STC. We are having trouble knowing how to correctly code this using the current 5010 X12 guide.

EB*B**AG**7*0*DY*20*Y*Y~
EB*B**AG**7*50*DY*100*Y*Y~
EB*A**AG**7**.20*D3*101-365*Y*Y~

Does this translate to Request suggested coding for following benefit: STC_AG Skilled Nursing Care.

Day 1-20 $0 Copayment
Day 21-100 $50 daily Copayment
Day 101-365 20% Coinsurance

Response

Your examples did not account for not used elements EB05 and EB08. Also, the EB10 data element has an attribute of ‘R’, integer and a hyphen would not be allowed in the element. The examples below assume the treatment start date is 01012018. The DTP segments are used to convey dates associated with the eligibility or benefits being identified in the 2110C/D loops.

EB*B**AG***7*0**DY*20*Y*Y~
DTP*193*D8*01012018~
DTP*194*D8*01202018~

EB*B**AG***7*50**DY*80*Y*Y~
DTP*193*D8*01212018~
DTP*194*D8*04102018~

EB*A**AG***7**.20*D3*265*Y*Y~
DTP*193*D8*04112018~
DTP*194*D8*12312018~

DOCUMENT ID
005010X279