Section title: Requests for Interpretation
RFI #
2428
Coinsurance Max
Description

Member has a OOP Max of 5,000 Single/10,000 Family. They also have a Coins Max of 1,000 Single/2,000 Family. What are the options for returning the Coins Max and Remaining in the 271 X12 response and also return the True OOP?    

Would this be correct?

EB*C*IND*30***22*2500*****W
EB*C*IND*30***29*2500*****W
EB*G*IND*30***22*5000*****W
MSG*MEDICAL AND DRUGS
EB*G*IND*30***29*4993.67*****W
EB*F*IND*4{5{62{73***22*300*****W
MSG*PAID AT 100% TO MAXIMUM LIMITATION THEN SUBJECT TO APPLICABLE DEDUCTIBLE AND COINSURANCE FOR OUTPATIENT LAB & X-RAYS
EB*F*IND*4{5{62{73***29*300*****W
EB*A*IND*4{5{62{73***22**.2****W
EB*G*IND*4{5{62{73***22*1000*****W
EB*G*IND*4{5{62{73***29*1000*****W

 

RFI Response

While the example you’ve provided appears correct, it does not explain what the $300 limitation/remaining is, and it does not further explain that the $1000 OOP is the coinsurance out of pocket maximum.  While technically this will work, it may not further provide clarity that the $1000 is a coinsurance out of pocket maximum.
 

RFI Recommendation

It is highly suggested that additional verbiage be sent in a MSG segment that identifies the limitation as a coinsurance out of pocket maximum, or a MSG segment that identifies the out of pocket as a coinsurance out of pocket maximum. Either EB01 = F or G would suffice, as it would depend on the information source’s preference and/or systematic functionality.

EB*C*IND*30***29*2500*****W
EB*G*IND*30***22*5000*****W
MSG*MEDICAL AND DRUGS
EB*G*IND*30***29*4993.67*****W
EB*F*IND*4{5{62{73***22*300*****W
MSG*PAID AT 100% TO MAXIMUM LIMITATION THEN SUBJECT TO APPLICABLE DEDUCTIBLE AND COINSURANCE FOR OUTPATIENT LAB & X-RAYS
EB*F*IND*4{5{62{73***29*300*****W
EB*A*IND*4{5{62{73***22**.2****W
EB*G*IND*4{5{62{73***22*1000*****W
MSG*Coinsurance out of pocket maximum; once coinsurance maximum is reached, no further coinsurance is collected
EB*G*IND*4{5{62{73***29*1000*****W
MSG*Coinsurance out of pocket maximum remaining; once maximum remaining is -0-, no further coinsurance is collected
EB*G*FAM*4{5{62{73***22*2000*****W
MSG*Coinsurance out of pocket maximum; once coinsurance maximum is reached, no further coinsurance is collected
EB*G*FAM*4{5{62{73***29*2000*****W
MSG*Coinsurance out of pocket maximum remaining; once maximum remaining is -0-, no further coinsurance is collected
EB*F*IND*4{5{62{73***22*1000*****W
MSG*Coinsurance out of pocket maximum; once coinsurance maximum is reached, no further coinsurance is collected
EB*F*IND*4{5{62{73***29*1000*****W
MSG*Coinsurance out of pocket maximum remaining; once maximum remaining is -0-, no further coinsurance is collected
EB*F*FAM*4{5{62{73***22*2000*****W
MSG*Coinsurance out of pocket maximum; once coinsurance maximum is reached, no further coinsurance is collected
EB*F*FAM*4{5{62{73***29*2000*****W
MSG*Coinsurance out of pocket maximum remaining; once maximum remaining is -0-, no further coinsurance is collected


Note: The future versions of the TR3 intend to restrict the ability to repeat information in the MSG segment that has been codified in segments or elements.

DOCUMENT ID
005010X279