In a 271, is there a way to express a coinsurance annual limit using coded data elements, or can this only be done using MSG segments? A health plan has an individual in-network out-of-pocket annual maximum of $8000 and a lower coinsurance annual maximum of $2000. Certain Service Type Codes have only a coinsurance percentage and other STCs have only a copayment dollar amount. Once a member spends $2000 in coinsurance in a calendar year, they no longer have to pay any more coinsurance for any service that year (the coinsurance percentage drops to 0%). The TR3 has EB01 (Eligibility or Benefit Information) code "G" which can be used to send the $8000 total out-of-pocket limit, but I do not see a suitable code to send the coinsurance spending limit or accumulator.
A commercial health plan has benefits that include both copayments and coinsurance, and the annual coinsurance maximum is lower than the annual out-of-pocket maximum. They are currently expressing that coinsurance maximum with MSG segments, and we are unsure whether this satisfies the segment situational rule.
In 005010X279A1, the ability to represent a coinsurance annual maximum dollar limit is not easily available. Using a combination of the EB01, EB08, EB09, EB10, and EB12 along with the MSG segment would be the best, most effective way to represent your scenario described in your question above.
EB*A*IND*any service type code***23**.2*M2*2000**Y~
MSG*Annual Coinsurance Limit Maximum $2000 dollar amount allowed to be collected from the patient within the calendar year (sample text format)~
EB*A*IND*any service type code***23***99*1900**Y~
MSG*Annual Coinsurance Limit dollar amount used to date collected from the patient within the calendar year (sample text)~
It is possible, but not preferred, to reflect the 2000 maximum using only the MSG segment, but WG1 recommends using EB09/EB10 as a more codifiable way to reflect the maximum 2000.
EB*A*IND*any service type code***23**.2***Y~
MSG*Annual Coinsurance Limit Maximum $2000 dollar amount allowed to be collected from the patient within the calendar year (sample text format)~
EB*A*IND*any service type code******Y~
MSG*Annual Coinsurance Limit dollar amount used is $$$$$.$$ to date collected from the patient within the calendar year (sample text format)~