CAQH/CORE representatives referred us to X12 for clarification
If a 270 is received that is “generic” and the payer always returns all benefit eligibility, does this satisfy both a generic and a explicit request? Or is it mandated that if a payer receives an generic 270 a generic response must be returned and if a explicit 270 is received an explicit response is required? Does a response with all eligibility in the response satisfy both types of requests?
See the TR3 page 22, bullet point #8.
CAQH/CORE stated that as per the CORE requirements , returning all STC benefit information for either a generic or a explicit request(270) would be acceptable, however there is still some confusion whether it would be compliant under the X12 standards defined in the TR3. If I receive a 270 requesting STC 30 (Generic) or an (Explicit) and I return a 271 with the eligibility for all STC’s per the highlighted documentation in the TR3 is that compliant.
X12N/TG2/WG1’s understanding of this request is that the health plan desires to return the same response for an explicit Service Type Code as they would for Service Type Code 30 - Health Benefit Plan Coverage (generic response) and would be including all of the explicit Service Type Codes required by the CAQH CORE Phase I & II Operating Rules.
Section 1.4.7.1 271 item 8 of the 005010X279 TR3 has the following requirements for responding to a Service Type Code 30:
“If an information source receives a Service Type Code "30" submitted in the 270 EQ01 or a Service Type Code that they do not support, the following 2110C/D EB03 values must also be returned if they are a covered benefit category at a plan level.
1 - Medical Care
33 - Chiropractic
35 - Dental Care
47 - Hospital
86 - Emergency Services
88 - Pharmacy
98 - Professional (Physician) Visit - Office
AL - Vision (Optometry)
MH - Mental Health
UC - Urgent Care
The above codes must have the appropriate EB01 = 1-5. If it is not a covered benefit, the code must not be returned. The repetition function of EB03 must be used if only reporting the Active Status or if Patient Responsibility is the same across multiple benefits. If any of the above benefits are associated with an other entity (e.g. carve out) the information must be returned in 2120C/D if known.”
Since this section prohibits returning any of the 10 Service Type Codes that are not covered benefit, the same response would not be possible if an explicit request was received for one of those benefits that are not covered. An explicit request for a not covered benefit would be returned with EB01 = “I” Non-Covered. Returning EB01 = “I” Non-Covered for any of the 10 Service Type Codes listed in Section 1.4.7.1 271 item 8 in response to a Service Type Code 30 would not be compliant with the requirements of the 005010X279 TR3 and 005010X279A1 Errata.
The last paragraph of Section 1.4.7.1 271 item 9 states “Additional covered Service Type Codes may be returned at the information source's discretion; however their absence does not imply that they are not covered.”
X12N cannot address how to create a response that would be compliant with the CAQH CORE Phase I & II Operating Rules.
X12N strongly encourages health plans work towards adapting their 271 responses to returning only the information that is relevant to the Service Type Code requested in the 270 request.