i'm working with a Payer customer who has a scenario that we can't figure out how to map it to X12. For service type code 42 there is a 1 time fee that they collect per year of $50 for home health. This is in addition to the normal $100 calendar year deductible. The customer states this 1x fee really isn't a deductble or co-pay. How should this be coded in x12?
Section 1.4.9 - Patient Responsibility of the TR3 reads in part:
"Health Plans have many different ways of identifying the patient's monetary responsibility when services are rendered. Depending on the type of plan the patient is enrolled in such as an HMO, PPO or traditional indemnity plan, the types of patient responsibility will vary. The most common of these are Co-Payment, Co-Insurance and Deductible."
"NOTE: Some health plans may use these terms differently than identified in this Implementation Guide, and the Implementation Guide definitions take precedence when used in conjunction with this transaction."
"C - Deductible"
"Deductible represents the total amount of the patient's portion of responsibility for a benefit and is represented as a dollar amount in EB07. The deductible amount is typically found in a fee for service environment and is based on the total amount the patient will have to pay before their benefits begin (which may then require co-insurance or co-payment)."
If the one-time Home Health fee meets the definition of deductible as defined in 1.4.9 it must be reported as a deductible in the EB01. The calendar year deductible would be reported as a general deductible such as Service Type 30, (EB*C*IND*30) and the one-time fee for Home Health would be reported with Service Type 42, (EB*C*IND*42).
If the one-time fee for Home Health does not meet the definition of deductible as described in section 1.4.9 then the MSG segment is used. The 2110C and 2110D MSG segments Situational Rules read:
“Required when the eligibility or benefit information cannot be codified in existing data elements (including combinations of multiple data elements and segments);
AND
Required when this information is pertinent to the eligibility or benefit response. If not required by this implementation guide, do not send.”
The free form text of the MSG01 can be used to identify benefit information that is not codified specifically in the EB01. The MSG01 must not include any information that is elsewhere codified such as the monetary amount of the benefit information that is sent in the EB07. The EB01 value would need to be what you deem most appropriate for the Benefit information being described.
If you have a business need not supported in a published TR3, you may submit a Designated Standards Maintenance Organizations (DSMO) request to http://www.hipaa-dsmo.org/.