Our benefit business area would like to communicate via a MSG segment the services that are covered as a benefit within a service type code. However, we are finding that some of these explanations could potentially be codified. An example of this is for service type code ‘33 – Chiropractic.’ Our business area would like to add a MSG segment that states “INCLUDES PHYSICAL THERAPY.” Our EDI area recognizes that this benefit explanation/description could be codified via service type code ‘PT;’ however, business believes this explanation further clarifies the scope of the Chiropractic benefit and must be reported to align included services and support provider satisfaction. We would appreciate X12Ns review and comment if adding this MSG segment would violate the MSG segment situational rule.
271 example:
EB*D*IND*33~
MSG*INCLUDES PHYSICAL THERAPY~
The answer to this question is complicated since it will depend on how the information source has coded the benefits in their system. The notion that services or benefits can be codified individually is accurate. The expected and appropriate 271 response would depend on whether the physical therapy services “count” towards the chiropractic benefits as it relates to the cost share(s) and shared (or not) accumulators, etc. With that, it would be inappropriate to return “Includes Physical Therapy” in a message segment. The response, when including a service type code PT for physical therapy, explicitly indicates that.
The complicated part of the answer is whether the response changes depending on “who” is sending the 270. If a physical therapist were to send a 33 service type code in the 270, would the response indicate that it’s not covered if the physical therapist is not contracted for chiropractic services?
In contrast, if the chiropractic provider submitted a PT on the 270 (and no 33), would the 271 indicate the physical therapy benefit is covered?
The indication of the 33 and the PT on the 271 doesn’t necessarily imply they’re separate and distinct from one another; therefore, the 271 should have the two specific services/benefits codified in EB03 using code values ‘33’ and ‘PT.’
EB*B**30***27*10~
EB*D*IND*33^PT~
The two segments above describe the scenario described by the submitter: Chiropractic and physical therapy services are covered services, and each has a 10$ copay per visit. One visit, inclusive of the physical therapy and chiropractic services, will have a single 10$ copay.
If the physical therapy services with respect to patient financials, or visit limits, etc. apply to chiropractic benefits, when returning the service type code PT, these benefit details would be withheld and the benefit details would be carried in the segment returning the chiropractic service type code.
It’s recommended that the information source use information from the 270 to determine what benefits would be returned to the information receiver/provider tailored to that provider. If physical therapy services/benefits are benefits covered by the information source for the provider identified on the inquiry, the response, when including PT and 33, would indicate these are both services covered for this provider for the member.