Situational Rule: "Required when needed to indicate if authorization or certification is required for the eligibility or benefits being identified in the 2110C loop. If not required by this implementation guide, do not send"
Should this be interpreted as "return EB11 when auth/cert is required per plan provision?"
1) A “Y” value indicates that an authorization or certification is required per plan provisions.
2) An “N” value indicates that an authorization or certification is not required per plan provisions.
3) A “U” value indicates it is unknown whether the plan provisions require an authorization or certification.
Or is the situational rule meant to state that returning EB11 is at the Information Source's discretion regardless if precert/preauth applies to the Plan Provision?
The original intent of this situational rule was to continue to allow this information be returned at the discretion of the health plan, just as it was in 004010X092, when needed by the health plan. The reasoning behind this is that the level of detail needed to make such a determination may not always be present in the 270 request (such as diagnosis codes).
If a particular benefit requires an authorization or certification, the health plan should return a Y in EB11. If a particular benefit does not require an authorization or certification, the health plan should return an N in EB11. 005010X279 includes instructions on the appropriate use of U in EB11. U is not to be used as a standard response.
Use of EB11 is highly advised when there is a financial impact when a benefit requires an authorization or certification.