Please provide clarification on how to appropriately structure two unique copay amounts for a single service. One copay is a “per visit” office visit copay subject to a specific provider type. The second copay is specific to the service type provided. The member is subject to both copays if services are performed by a specific provider type.
Can this scenario be structurally supported in a 271 response a provider can clearly interpret? If not, is there an alternative or recommended way to convey this information in a compliant response?
This situation applies to certain DMO dental plans. If services are rendered by general dentists, both the "per visit" office copay would apply, in addition to an ADA copay. For services rendered by a specialty provider, only the ADA copay would apply (no "per visit" office copay).
This scenario can be supported to a degree. It sounds like the patient could have two copays. Either or both copays apply, depending on whether a general or specialty provider type is doing the service. Technically, since the EB’s are “like” level segments (same position), there is no assumed overriding, priority ordering nor bundling, so two EB’s for the same service type code or procedure code would likely couple with a 2110 PRV that could narrow the patient financial responsibility. Generically showing the office visit has a copay with the taxonomy, and which taxonomies have additional copay requirements, is the most direct way to convey the information but could be tedious for the information source to source and could be something the information receiver will need to have clearly detailed out for implementation.
Another option, if the copays are the same, regardless of the specialty type, is using the MSG segment to convey that the copay in the EB07 is applicable dental service type code (or a CDT procedure code) rendered or performed by specialty dental providers.
Where the same copay amount applies to any dental specialty provider the following would be returned; despite the usual recommendation to use the MSG segment, it is most efficient here as there are a number of dental taxonomy codes that would have to be returned all with the same copay dollar amount in EB07.
As the office visit is one copay, we opted to use the service type code “98 – Physician (Professional) Visit - Office” as that is most directly indicative of the office visit by way of the code value description.
As for the additional copay, which is dependent on the specialty type of the provider, as it is described above as not being “per visit,” we opted to use “25 – Contract”. However, if the information source deems it appropriate to return “27 – Visit” in EB06 for the second EB below, it is recommended to be returned as it may be clearer to the information receiver than “25 – Contract”.
EB*B*IND*98*HM*DMO*27*30*****Y~
LS*2120~
PRV*PE*PXC*1223G0001X~
EB*B*IND*35*HM*DMO*25*75*****Y~
MSG*Copay for services rendered/performed by a specialty provider, regardless of specialty~
If copays are different depending on the specialty, the following would be returned, if the dental payer has the ability to report based on different taxonomy and their associated copay amount levels.
As is for above, if, for the additional copay, which is dependent on the specialty type of the provider, is described as not being “per visit” but rather per contract, we opted to use “25 – Contract”. However, if the information source deems it appropriate to return “27 – Visit” in EB06 for the second EB below, it is recommended to be returned as it may be clearer to the information receiver than “25 – Contract”.
EB*B*IND*98*HM*DMO*27*30*****Y~
LS*2120~
PRV*PE*PXC*1223G0001X~
LE*2120~
EB*B*IND*35*HM*DMO*25*75*****Y~
LS*2120~
PRV*PE*PXC*1223E0200X~
LE*2120~
EB*B*IND*35*HM*DMO*25*55*****Y~
LS*2120~
PRV*PE*PXC*1223P0300X~
LE*2120~
EB*B*IND*35*HM*DMO*25*25*****Y~
LS*2120~
PRV*PE*PXC*124Q00000X~
LE*2120~
EB*B*IND*35*HM*DMO*25*45*****Y~
LS*2120~
PRV*PE*PXC*1223P0700X~
LE*2120~
EB*B*IND*35*HM*DMO*25*65*****Y~
LS*2120~
PRV*PE*PXC*1223S0112X~
LE*2120~
EB*B*IND*35*HM*DMO*25*15*****Y~
LS*2120~
PRV*PE*PXC*126800000X~
LE*2120~
EB*B*IND*35*HM*DMO*25*15*****Y~
LS*2120~
PRV*PE*PXC*125J00000X~
LE*2120~
EB*B*IND*35*HM*DMO*25*105*****Y~
LS*2120~
PRV*PE*PXC*1223D0004X~
LE*2120~
Related RFI: #2350