Is this out of compliance with 271 Standards, 1.4.12 Message Segments? "Under no circumstances can an information source use the MSG segment to relay information that can be sent using codified information in existing data elements (including combinations of multiple data elements and segments). Information that has been provided in codified form in other segments or elements elsewhere in the 271 for the individual must not be repeated in the MSG segment."
Payer is telling us on the phone and via their website that an MRI/CT should be $150 copay. The Payer is not telling us that in the 271. They are telling us it is a $100 copay:
287.) EB*B*IND*62**BASIC*27*100*****Y~
The Payer is telling us it is listed in the 50-Hospital - Outpatient Services:
166.) EB*B*IND*50**BASIC*7*150*****Y~
167.) MSG*PREFERRED AND PARTICIPATING FACILITY; BONE DENSITY, ANGIOGRAPHY, CT SCANS/MRIS/PET SCANS, GENETIC TESTING, NUCLEAR MEDICINE~
When asked again, they said, "Our team has worked with the payer to gain a better understanding of the 271 responses as it relates to CT/MRIs performed in an outpatient setting. If Service Type Code 62 and 50 is returned on an eligibility response specific to payer’s policies, the outpatient facility benefits for a CT/MRI will be found under Service Type Code 50. The Service Type Code 62 for payer’s policies will be specific to professional CT/MRI benefits only."
The best approach is to return information that clearly identifies service. As message segments require human interpretation, and, because CT and MRIs can be codified using service type code 62, it appears the key difference with the above response is the identification of the benefit being categorized as a professional or facility benefit. Because 005010X279A1 does not have a solution to identify benefits as professional or facility, the above response is technically allowed assuming the services listed in the MSG segment collectively have a $150.00 copay. If this is not the case, the services need to be broken out in individual EB segments using either EB03 or EB13.
If the $150.00 copay covers these services collectively as part of their outpatient facility benefits, the information source’s response can be better represented as follows:
Professional benefits:
EB*B*IND*62**BASIC*27*100*****Y~
MSG*Professional benefits only~
Institutional/facility outpatient benefits:
EB*B*IND*50**BASIC*7*150*****Y~
MSG*PREFERRED AND PARTICIPATING FACILITY; BONE DENSITY, ANGIOGRAPHY, PET SCANS, GENETIC TESTING, NUCLEAR MEDICINE~
EB*B*IND*62**BASIC*7*150*****Y~
MSG*PREFERRED AND PARTICIPATING FACILITY; OUTPATIENT FACILITY BENEFITS ONLY ~
The best way to represent the different copays for the professional and facility benefit structure beyond that of what we have outlined above, making it even clearer and consistent with the requirement in 1.4.12 Message Segments of the front matter, the information source may want to consider the following:
- Using the EB13 to indicate the other services (BONE DENSITY, ANGIOGRAPHY, PET SCANS, GENETIC TESTING, NUCLEAR MEDICINE) and provide an MSG segment that indicates the benefits’ outpatient facility relationship.
- If applicable, using the III02 to indicate where the place of service of the benefit delivery may occur.
Part of the question above referring to “…Information that has been provided in codified form in other segments or elements elsewhere in the 271 for the individual must not be repeated in the MSG segment" is text from a future version of the TR3 and is not included in the 005010X279A1 HIPAA mandated TR3.
Related RFIs: 991, 992