We have a question about the most appropriate EB03 value to return in a 271 to explain coverage for a telemedicine benefit (telephone visit with a doctor who might or might not be the member's PCP). We want to be able to convey to a provider if the member they are inquiring about has coverage for the telemedicine benefit or not so the provider knows whether the service would be covered and what the copay/coinsurance amount would be.We have not been able to find a value in the EB03 list of codes which clearly matches this situation.
As you state there is not currently a code available in the EB03 code list to specifically identify a “telemedicine benefit”.
Note: Please refer to RFI #2486. There has been a new code added to support Telemedicine that was not available at the time this RFI #1957 was published.
Use of a suitable existing EB03 code such as ‘3 Consultation’ could be used in conjunction with the MSG segment (element MSG01) providing the information that the service is telemedicine, e.g. MSG*TELEMEDICINE BENEFIT~ To have consideration given to adding a new Health Care Service Type code used in EB03 (and in the EQ01 of the 270). use this link http://www.wpc-edi.com/reference/codelists/healthcare/health-care-service-type-codes/ and complete a Change Request Form. Please note this external code set list for Service Types Code applies to TR3 versions starting with version 6020.