What would be the best DTP to use to reflect the redetermination dates in both 005010 and 008060? We are seeing them come through in message segments, and optimally it would be good to have an official way to reflect them, especially in light of the OBBBA. Is there a plan to have an official redetermination qualifier?
Medicaid will be redetermining eligibility every six months and checking for work/activity. We are seeing this come in transactions in EB*D's, and EB*W's with a message, DTP 458, 540 with a message that this is redetermination. The easiest way to identify now is in a message segment for many payers.
As 005010X279A1 is the mandated version of the 270/271 Health Care Eligibility Benefit Inquiry & Response, this response is speaking to that version only.
The 271 is equipped to return the DTP at both the 2100 and 2110 loop levels. If it’s to re-certify that the member has met their eligibility requirements (or not), the simplest way to return whether or not a member is eligible, regardless of it being a redetermined eligibility (rendering either upkeep of the same enrollment/eligibility or cancellation as the work/activity requirements were not met), would be to return “active” or “inactive” as to their status for the date of service in question.
Depending on the date of service, the following code values could be useful, but this is not a complete, nor exhaustive list as other code values listed in EB01 may be used, depending on the payer’s applicable use case:
356 Eligibility Begin
357 Eligibility End
636 Date of Last Update
771 Status
While the above values are available at both the 2100 and 2110 loop levels, code value 458 – Certification is only available at the 2100C (or D) loop levels. The most appropriate values to return would be the EB01 = 1 or 6 (Active Coverage or Inactive Coverage). If the coverage is “inactive” but the information source is awaiting an update from a source on the coverage, EB*7 Inactive – Pending Eligibility Update would be best. Only when there is no eligibility information should EB*D be used; EB*W should only be used if the 2100A information source who received the 270 is not the source of that status information.
While certainly not preferred, EB*U (Contact the Following Entity for Eligibility or Benefit Information) is an acceptable way to provide information; however, this will likely drive up call volume as a means to obtain information from the information source that was not available electronically. Some would argue the same information should be made available for an electronic 270/271 exchange as is available for a call when determining eligibility and benefits.