For the first EB segment in the 2110C loop, which is more correct? If only option A was used how would the provider know the 271 is only for behavioral health benefits? If only option B was returned, would the benefits manager be sending a compliant 271? If not, what EB segments should be returned?
option A: EB*1**30*C1*PLAN NAME HDHP HMO 20% AFTER DED OP 80% AFTER DED
option B: EB*1**MH
A provider queries eligibility for a patient's insurance plan. The provider believes the plan is medical insurance, so sends their 270 with a Service Type Code (STC) of 30. This 270 is inadvertently routed to the organization that manages only the behavioral health portion of the patient's benefit.
Facts that came to light during the investigation:
1. The patient does have active medical coverage through insurance company X.
2. Behavioral health benefits are managed by a separate organization. We will call this organization the behavioral health benefits manager or BH benefits manager for short.
3. The transaction was miss routed because the provider inadvertently queried the right payor, but the wrong database.
4. The 270 contained the ID # for the medical portion of the plan
5. The 271 returned the ID # for the behavioral health portion of the plan
6. The provider's system would interpret the above options as follows:
option a: active commercial medical coverage
option b: active behavioral health coverage
It is outside of X12’s purview to comment on a payer’s policy or procedure.
Contact the payer to report the results the transaction is returning.