Section title: Requests for Interpretation
RFI #
2350
Tiered CoPay
Description

Our provider would like to know whether we can derive real-time benefit information on claim coverage reliant on visit number limitations. For instance, if an request came in for a member who has coverage for 5 visits, and already has had 6 visits, could the response alter the co-pay to reflect they've exceeded their limit?
I found RFI #719 which is very similar. Using that as a basis for, the first five visits for a service type code are subject to one co-pay amount and visits that exceed five have a different co-pay

The EB and HSD segments could be displayed:
EB*B**98****20*****N~ (Co-Pay 20, OON)
HSD***VS**31*5~ (Visits Not Exceeded 5)

EB*B**98****40*****N~ (Co-Pay 40, OON)
HSD***VS**30*5~ (Visits Exceeded 5)

Would this be correct?

Response

Yes, this information can be included on the 5010 271 response. The proposed response is close, but would require one more EB loop and some slight changes.

RFI Recommendation

If it can be determined what tier based on visits used should be returned to the provider the response would include segments as follows:
EB*B**98***27*20*****N~ (Co-Pay $20 per visit, OON)
HSD***VS**31*5~ (Visits Not Exceeded 5)
If it cannot be determined what tier based on visits used should be returned to the provider the response would include segments as follows:
EB*B**98***27*20*****N~ (Co-Pay $20 per visit, OON)
HSD***VS**31*5~ (Visits Not Exceeded 5)
EB*B**98***27*40*****N~ (Co-Pay $40 per visit, OON)
HSD***VS**30*5~ (Visits Exceeded 5)
Note: EB04 and EB05 should always be included to note which plan in the response this set of benefit information applies to. It was omitted from this example because there are not sufficient details in the request to know what to include.

EB*B**98***27*40**99*6**N~ (Co-Pay $40 per visit, OON, 6 visits used)
HSD***VS**30*5~ (Visits Exceeded 5)

DOCUMENT ID
005010X279