Please advise the proper way to convey the benefit below in the 271. Are message segments the only option with the current version?
The benefit is for service type code Frames. The member cost-share varies based on the total cost of the frames.
For example: (We can assume that 'cost' = 'submitted charge'.)
Copay is $15 for frames costing up to $130
Copay is $30 for frames costing $130 and up to $175
Copay is $45 for frames costing $175 and up to $250
Coinsurance of 40% for frames costing over $250
Yes, with version 5010, a combination of EB and MSG segments would be the only option to convey the benefits above.
Example below illustrates how EB01, EB03, and EB07/EB08 elements in the EB segment, and MSG segment can be coded.
EB*B*IND*AM****15~
MSG*For costs up to $130~
EB*B*IND*AM****30~
MSG*For costs between $130 and up to $175~
EB*B*IND*AM****45~
MSG*For costs between $175 and up to $250~
EB*A*IND*AM*****.4~
MSG*For costs over $250~
It's recommended that information conveyed in the MSG segment not repeat information elsewhere in the 271 in codified form. Use of a separate EB with EB06 conveying the frequency of the benefit may help.
Note: The scenario above may not require MSG segments in a future version designed to handle tiered benefits.