Section title: Requests for Interpretation
270/271 5010 Section 1.4.9

Section 1.4.9 Patient Responsibility section of the 270/271 5010 front matter discusses different types of patient responsibility and then defines each of the common ones and how to use them.

Each description is followed by the statement that if the patient’s portion of the responsibility for the benefit is nothing, then a “0” should be returned.

Is returning the 0 amount when considering each type of patient responsibility (copay, coinsurance, etc) or is this when looking at all levels of patient responsibility as a whole?

For example, if the benefit has a copay, but no coinsurance associated with it, do you still return the coinsurance line with a 0 listed for the coinsurance amount, or just return the copay amount with no coinsurance line?

Or, do you only use the 0 if the member has no copay, coinsurance, deductible, out of pocket, cost containment, or spend down and then you return all of them with the 0 amounts?

RFI Response

005010X279 does not require the return of patient responsibility. Absence of patient responsibility does not imply that a patient financial responsibility does or does not exist. To identify that a benefit has a copay and no coinsurance as represented in the example above, the correct response would include two EB segments, one EB with a copay in EB01 and the dollar amount in EB07, and one EB with the coinsurance in EB01 with a “0” percentage amount in EB08.