In a version 005010 271 transaction, what is the best practice for an information source (payer) to indicate that frequency limits on a benefit are shared across multiple discrete procedure codes? The EB13 field allows for a single procedure code (like a CPT or CDT), or a range of such codes, but it does not allow multiple separate codes. We have been receiving 271 transactions from dental payers with Loop ID-2110C content like this. They put a Service Type Code in EB03, leave EB13 empty, and then specify the actual CDT codes in MSG01.
EB*F**41***23***P6*2**Y~
MSG*TOPICAL APPL OF FLUORIDE - EXCL VARNISH~
MSG*per calendar year (shared frequency with D1206 and D1208)~
Is there a better way to represent that benefit using discrete data elements? Or if not, could you recommend a good format to use in MSG01?
In later versions of the 271 transaction, the EB13 field allows repetitions so it can contain multiple procedure codes. This question is only about the current HIPAA standard version 005010.
Our customers are receiving 271 eligibility response transactions from dental payers and are having difficulty parsing them in a consistent way.
In today’s 005010X279A1 TR3, we do not have a way to provide a response that would be better parsable. As pointed out above, in future versions, we not only changed EB13 to repeat, but we also allow EB03 and EB13 to return on the same EB segment (where the circumstance fits) and, additionally, introduced a new value (EB15) that allows the information source to indicate if shared limitations exist between service type codes and/or procedure codes.
Unfortunately, as that version is not the HIPAA-mandated version, the best approach is more difficult to introduce.
While there is not a firm best practice, an alternate option to relay the information could be done as follows, if returning the Service Type Code 41 is not critical with the procedure codes:
EB*F**41***23***P6*2**Y~
MSG*TOPICAL APPL OF FLUORIDE - EXCL VARNISH~
EB*F*****23***P6*2**Y*AD:D1206~
MSG*shared frequency limitation with D1208~
EB*F*****23***P6*2**Y*AD:D1208~
MSG*TOPICAL APPL OF FLUORIDE - EXCL VARNISH~
MSG*shared frequency limitation with D1206~
EB*F*****23***P6*2**Y*AD:D1351~ ***SEE NOTE***
MSG*shared frequency limitation with D1352~
EB*F*****23***P6*2**Y*AD:D1352~ ***SEE NOTE***
MSG*shared frequency limitation with D1351~
***Note, these CDT codes above are for example purposes only.