Section title: Requests for Interpretation
RFI #
2343
Multiple plans & member IDs
Description

For members with multiple plans that have a different member ID for each plan, we would like to confirm how to return eligibility. For example, the member has a Medicare & a Medicaid plan or a commercial plan & a Medicaid plan. We have reviewed several RFIs and believe it would be compliant to return the following. Please confirm if this is correct or if there is a more appropriate way to return the multiple plans with their corresponding member ID on the 271.

Example Medicare & Medicaid:
2100C NM109 – Medicaid ID
2110C EB05 – (Medicaid Plan Name)
2110C DTP - (Dates of coverage for Medicaid)

2110C EB*R**30*HN*(Medicare Plan Name)
2110C DTP - (Dates of coverage for Medicare)
2110C REF02 - (Medicare Member ID)
2120C NM1*PR*2*(Medicare)

Response

The response would be dependent on the member ID that was submitted in the inquiry. Assuming the inquiry had a Medicaid ID submitted in the 270, your response would be correct. If there is a Medicaid ID that is submitted on the 270, the Medicaid plan would be returned, with the Medicare plan listed in the 2120C loop; this would be done with an EB01=R in the 2110C loop carrying the 2120C Medicare plan/member information. See section 1.4.7.1, Item 6, which outlines the scenario when a member has more than one plan or payer. It does not address what level of information must be returned, however it would serve the member and the provider best to return as much known information as possible that allows the provider to do a second 270 to the payer listed in the 2120C loop.

RFI Recommendation

Dates of coverage in the 2110C DTP carrying the Medicare plan information may conflict with the above section 1.4.7.1 Item 6 whereby it states the “Do not return details of coverage or benefits associated with other payers or plans”. Dates of coverage may be considered “details” of coverage. Please use caution when returning information related to coverage or benefits for the “other” plan. Also, the Medicare Member ID could be sent in either the 2110C REF or the 2120C NM1. The recommendation is to return the Medicare/Additional Payer Member ID in the 2120C, as shown below.

2110C EB*R**30*HN*(Medicare Plan Name)
2110C DTP - (Dates of coverage for Medicare)
2120C NM1*PR*2 --- (Medicare)
2120C NM1*IL*1 --- (Medicare Member ID)

DOCUMENT ID
005010X279