Upon researching this issue, we believe that RFI #2047 and #2059 seem to allow the following approach for our rate schedule scenario:
EB*D****MEMBER RATE SCHEDULE**30*****Y*AD:D0120~
MSG*COINSURANCE IS THE DIFFERENCE BETWEEN THE MEMBER RATE SCHEDULE AND THE IN-NETWORK PROVIDER ALLOWED AMOUNT~
EB*D****MEMBER RATE SCHEDULE**30*****N*AD:D0120~
MSG*COINSURANCE IS THE DIFFERENCE BETWEEN THE MEMBER RATE SCHEDULE AND THE OUT-OF-NETWORK PROVIDER BILLED AMOUNT~
Can X12 provide guidance on this approach and offer any additional suggestions on how to be more clear in the scenario given?
Our plan has a unique dental benefit plan design that does not seem to be addressed by the 005010X279 TR3. The plan features a list of procedures with an associated "member rate schedule" for each code. Each code has a dollar amount value assigned that represents the maximum reimbursement under that plan. Our intent is to return this data in a 271 since it is the only manner that we can convey patient liability for the plan as blanket coinsurance/copay amounts do not apply.
An example for how this applies to In-Network and Out-of-Network providers is as follows:
Precondition:
-Procedure code D0120 has a member rate schedule amount of $30.
-Member is eligible for a given AsOf on a member rate schedule plan.
In-Network:
Member sees an in network provider and receives care under D0120. Provider bills $40, but their allowed amount for that service is $32.
RESULT: $32 (allowed amount) - $30 (member rate schedule) = $2 (patient liability).
Out-of-Network:
Member sees an OON provider and receives care under D0120. Provider bills $47.
RESULT: $47 (OON billed amount) - $30 (member rate schedule) = $17 (patient liability).
Based on the follow-up responses from the submitter of this RFI, the EB*D with the term “member rate schedule” in EB05 would not be a valid use of the EB05 element per the EB05 element note “This element is to be used only to convey the specific product name or special program name for an insurance plan. For example, if a plan has a brand name, such as “Gold 1-2-3", the name may be placed in this element. This element must not be used to give benefit details of a plan.” As “member rate schedule” is not a specific plan name or special program name, it is also not a “brand” name, there is no way to designate the amount sent in EB07 is pulled from the member rate scheduled tied to that plan.
The use of the MSG segment to indicate that the amount provided is defined by the member rate schedule is an acceptable, albeit not preferred, way to describe the value in EB07.
It’s suggested that the use of the 832 Health Care Fee Schedule transaction be explored to return the information to the provider to use the 832 Health Care Fee Schedule transaction to send the fee/rate schedule information electronically, perhaps when the information source receives a 270, a 271 response be returned, identifying the member’s eligibility and coverage status, and also then an 832 Health Care Fee Schedule transaction be sent independently to the provider with the member rate schedule information. The response should indicate either the in network or out of network rates, not both, if appropriate.
It's recommended that a maintenance request be submitted to accommodate the capability that is currently lacking to provide fee schedule information in the 270/271 TR3. Please see https://x12.org/resources/forms/maintenance-requests