In a version of the 005010 271 transaction within Loop ID-2110C/D for EB01 = "F" (Limitations), is it allowed to set a placeholder EB07 (Benefit Amount) value such as "999999.99" to assert that there is no monetary limit (unlimited)? Here is a fragment of a transaction we received:
EB*F*IND*PT***23*999999.99**VS*60~
MSG*REHABILITATIVE~
EB*F*IND*PT***29*999999.99**VS*60~
MSG*REHABILITATIVE~
We have confirmed in the payer's web portal that this benefit is monetarily unlimited; there is not actually a $999,999.99 limit for physical therapy. The actual limit is on number of visits, which is correctly shown in EB09 and EB10. The EB07 value is syntactically valid for the "R" (Decimal) data type, but since it does not match the plan member's real benefit, is this a violation?
A large commercial payer is sending us 271 transactions containing placeholder EB07 values. This might be related to RFI #848 but involves a different scenario.
For this example, it is not appropriate to return the EB07 with 999999.99 as this is an upper limit of just one penny less than one million dollars. For this reason, it is not correct to return a dollar amount and expect it to represent that there is no maximum.
The use of the MSG segment is a valid option in this scenario to advise the information receiver that no maximum dollar amount exists for the benefit. Using the MSG segment in combination with the EB01 value of "H – Unlimited" and moving the 60 visits maximum to the HSD segment will assist in addressing this scenario compliantly.
If this is functionality that is needed for your business and not currently supported in a published TR3, submit an X12 maintenance request at https://x12.org/resources/forms/maintenance-requests.