Section title: Requests for Interpretation
EB11 and Sit Rule Conflicts

EB11's situational rule says: Required when needed to indicate if authorization or certification is required for the eligibility or benefits being identified in the 2110C loop. If not required by this implementation guide, do
not send.

The way this situational rule can be read is: if the authorization requirement is not required, meaning not = Y, then this element must not be sent. However the note on EB11 re: U if not accessible or the rules are more complex than can be determined.

The N is even more unclear if it's allowed to be returned as there's no TR3 element note that seems to explain an allowance, and the situational rule seems to only imply that Y is the only valid value to be returned.

Does this mean N is not allowed?

RFI Response

Loop 2110C EB11 (DE1073) in the 005010X279A1 permits values of ‘Y – yes’, ‘N – no’, or ‘U – unknown’ as shown in the TR3.  The Situational Rule indicates EB11 is sent when there is a need to indicate whether prior authorization is required. The indication of requirement can be Yes, No or Unknown. The situational rule condition of whether to send EB11 is not based on what the requirement for prior authorization is, only whether there is a need to indicate the requirement for prior authorization.