I would appreciate additional clarification related to RFI #1762. If an information source (payer) has to reject a transaction due to a problem with the contents of the 270 Loop 2110C (Subscriber Eligibility or Benefit Inquiry), is there any guidance or limitations on which specific 271 Loop 2110C EB01 codes can or cannot be used in combination with an AAA segment in the same loop? Specifically, would it be a violation for the payer to send this set of segments?
EB*6**35*GP~
AAA*Y**15*R~
MSG*Exception=Member does not have current coverage~
It would not seem to make sense for the payer to assert that coverage is inactive if the transaction were rejected. A rejected transaction implies that the patient's eligibility (active or otherwise) was not determined.
A commercial dental payer is returning 271 transactions where Loop 2110C has EB01 = "6" (Inactive) and AAA03 = "15" (Required application data missing). We are unclear on how to interpret that or whether it is a violation of the TR3.
The situational rule for the 2110C AAA segment states that it is "Required when the request could not be processed at a system or application level when specifically related to specific eligibility/benefit inquiry data contained in the original 270 transaction's subscriber eligibility/benefit inquiry information loop (Loop 2110C) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send." Additionally, Section 1.4.10 of the TR3 states, "A 271 Eligibility, Coverage or Benefit Information response transaction must contain at least one EB (Eligibility or Benefit Information) segment or one AAA (Request Validation) segment." The section further states, "The AAA Request Validation segment is used to identify why an EB Eligibility or Benefit Information segment has not been generated or in essence, why the 270 Eligibility, Coverage or Benefit Inquiry has been rejected."
Returning an AAA segment rejecting the 270 inquiry within the 2110C level—indicating required application data is missing—is not supported by the situational rule (above) on the 2110C AAA segment as it conflicts with the statement that the rejection at this level is about the content sent on the 270 (which means, application data is NOT missing).
For this example, above, if accurate determination of eligibility can be made (such as a status of “inactive” using EB01=6), then the AAA and MSG above must not be sent. If the eligibility status cannot be determined, then the EB01 should not be returned, and the AAA should indicate what is missing or invalid that caused a lack of eligibility determination. The only time the AAA is allowed to be used at the 2110C(D) loop level is to indicate that something in the corresponding 270 2110C(D) loop level caused the rejection or inability to determine eligibility or benefits.
Depending on the use case and error encountered, a more appropriate response to return would be an EB01 = V (Cannot process) with the 2110C(D) AAA03 = 33 (Input errors), if a more specific AAA03 code value is not available, and then indicate in the MSG segment what should be sent in the 270 on resubmission. At this point, if no eligibility status can be determined, no EB01 of 1–8 should be returned.