Section title: Requests for Interpretation
Reporting a copay maximum accumulation in the 270/271

Is there a way to report a copayment maximum accumulation amount in the RTE transaction?


Medicaid plan has a monthly limit on the amount of copay a member is required to pay. The limit is based on a % of the member’s income. Member is only responsible for copays up to 5% of their monthly income. Report the amount of the limit used and the amount remaining.

RFI Response

To return the information compliantly, the best approach is to use EB01 = B or C and return the calculated amount in EB07 with an EB06 = 31 (Not exceeded) to indicate the “maximum.” Pairing this EB segment carrying the calculated amount with the HSD segment, returning HSD01 = MN (Month), HSD02 = 1 (as in every month) will provide the amount and the frequency.

Return a second EB segment and sending the remainder amount using EB06 = 29 (Remaining).

The recommendation above assumes that the monthly maximum calculation is done through a different process that is outside of the context of the 271.