How should a Payer identify a situation that is NOT APPLICABLE and/or that DOES NOT APPLY?
Because the Payer is sending zeros (0) for IND instead of not sending anything at all (because it does not apply), the system interprets a zero as just that: $0.00. So, as you can imagine, we now have no way of knowing that the patient really does not have this and we do not know if they have met their deductibles, met their out of pocket, no longer owe copays, and/or do not have a charge for specific services. This patient does not have an IND plan, they have a FAM plan; but, because the Payer gives us this in their 271, we do not know that.
Line 72: EB*C*IND*30^UC^AG^A0^99^96^52^7^62^50^5^48^42 ^4^18^13^12^11^PT^MH^DM^CJ^CI^BY^BV^BU^BT^BH^BB^AI^ AE^AD^A8^A7^A6^A5^98^93^78^69^65^6^53^47^34^33^3^20^2*GP**23*0*****Y~
Line 74: EB*C*IND*30^UC^AG^A0^99^96^52^7^62^50^5^48^42^4^18^13^ 12^11^PT^MH^DM^CJ^CI^BY^BV^BU^BT^BH^BB^AI^AE^AD^A8^A7^A6^ A5^98^93^78^69^65^6^53^47^34^33^3^20^2*GP**23*0*****N~
Line 76: EB*C*IND*EQ*GP**23*0*****N~
Line 80: EB*C*IND*EG*GP**23*0*****N~
Line 84: EB*C*IND*EQ*GP**23*0*****Y~
Line 88: EB*C*IND*EG*GP**23*0*****Y~
Line 92: EB*C*IND*VY^20^VZ^BV^BU^BT^BH^93^3*GP**23*0*****N~
Line 96: EB*C*IND*VY^20^VZ^BV^BU^BT^BH^93^3*GP**23*0*****Y~
Line 100: EB*G*IND*30^UC^AG^A0^99^96^52^7^62^50^5^48^42^4^18^13^12^ 11^PT^MH^DM^CJ^CI^BY^BV^BU^BT^BH^BB^AI^AE^AD^A8^A7^A6^A5^98^93 ^78^69^65^6^53^47^34^33^3^20^2*GP**23*0*****Y~
Line 102: EB*G*IND*30^UC^AG^A0^99^96^52^7^62^50^5^48^42^4^18^13^12^11^PT ^MH^DM^CJ^CI^BY^BV^BU^BT^BH^BB^AI^AE^AD^A8^A7^A6^A5^98^93^78^69^65 ^6^53^47^34^33^3^20^2*GP**23*0*****N~
Line 104: EB*G*IND*EQ*GP**23*0*****N~
Line 108: EB*G*IND*EG*GP**23*0*****N~
Line 112: EB*G*IND*EQ*GP**23*0*****Y~
Line 116: EB*G*IND*EG*GP**23*0*****Y~
Line 120: EB*G*IND*VY^20^VZ^BV^BU^BT^BH^93^3*GP**23*0*****N~
Line 124: EB*G*IND*VY^20^VZ^BV^BU^BT^BH^93^3*GP**23*0*****Y~
Line 148: EB*C*IND*30^UC^AG^A0^99^96^52^7^62^50^5^48^42^4^18^13^12^ 11^PT^MH^DM^CJ^CI^BY^BV^BU^BT^BH^BB^AI^AE^AD^A8^A7^A6^A5^98 ^93^78^69^65^6^53^47^34^33^3^20^2*GP**29*0*****N~
Line 150: EB*C*IND*30^UC^AG^A0^99^96^52^7^62^50^5^48^42^4^18^13^12^11^PT
^MH^DM^CJ^CI^BY^BV^BU^BT^BH^BB^AI^AE^AD^A8^A7^A6^A5^98^93^78^69^65 ^6^53^47^34^33^3^20^2*GP**29*0*****Y~
Line 152: EB*C*IND*EQ*GP**29*0*****N~
Line 154: EB*C*IND*EQ*GP**29*0*****Y~
Line 158: EB*C*IND*EG*GP**29*0*****Y~
Line 164: EB*C*IND*EG*GP**29*0*****N~
Line 168: EB*C*IND*VY^20^VZ^BV^BU^BT^BH^93^3*GP**29*0*****Y~
Line 172: EB*C*IND*VY^20^VZ^BV^BU^BT^BH^93^3*GP**29*0*****N~
Line 176: EB*G*IND*30^UC^AG^A0^99^96^52^7^62^50^5^48^42^4^18^13^12 ^11^PT^MH^DM^CJ^CI^BY^BV^BU^BT^BH^BB^AI^AE^AD^A8^A7^A6^A5^98 ^93^78^69^65^6^53^47^34^33^3^20^2*GP**29*0*****Y~
Line 177: EB*G*IND*30^UC^AG^A0^99^96^52^7^62^50^5^48^42^4^18^13^12^11 ^PT^MH^DM^CJ^CI^BY^BV^BU^BT^BH^BB^AI^AE^AD^A8^A7^A6^A5^98^93 ^78^69^65^6^53^47^34^33^3^20^2*GP**29*0*****N~
Line 180: EB*G*IND*EQ*GP**29*0*****Y~
Line 184: EB*G*IND*EG*GP**29*0*****Y~
Line 188: EB*G*IND*EQ*GP**29*0*****N~
Line 192: EB*G*IND*EG*GP**29*0*****N~
Line 196: EB*G*IND*VY^20^VZ^BV^BU^BT^BH^93^3*GP**29*0*****N~
Line 198: EB*G*IND*VY^20^VZ^BV^BU^BT^BH^93^3*GP**29*0*****Y~
Line 255: EB*C*IND*9*GP**23*0*****N~
Line 259: EB*C*IND*9*GP**23*0*****N~
Line 263: EB*C*IND*9*GP**23*0*****N~
Line 267: EB*C*IND*9*GP**23*0*****N~
Line 273: EB*C*IND*9*GP**23*0*****Y~
Line 277: EB*C*IND*9*GP**23*0*****Y~
Line 281: EB*C*IND*9*GP**23*0*****Y~
Line 285: EB*C*IND*9*GP**23*0*****Y~
Line 291: EB*G*IND*9*GP**23*0*****N~
Line 295: EB*G*IND*9*GP**23*0*****N~
Line 299: EB*G*IND*9*GP**23*0*****N~
Line 303: EB*G*IND*9*GP**23*0*****N~
Line 307: EB*G*IND*9*GP**23*0*****Y~
Line 311: EB*G*IND*9*GP**23*0*****Y~
Line 315: EB*G*IND*9*GP**23*0*****Y~
Line 319: EB*G*IND*9*GP**23*0*****Y~
Line 323: EB*C*IND*9*GP**29*0*****Y~
Line 327: EB*C*IND*9*GP**29*0*****N~
Line 331: EB*C*IND*9*GP**29*0*****N~
Line 335: EB*C*IND*9*GP**29*0*****N~
Line 339: EB*C*IND*9*GP**29*0*****N~
Line 343: EB*C*IND*9*GP**29*0*****Y~
Line 347: EB*C*IND*9*GP**29*0*****Y~
Line 351: EB*C*IND*9*GP**29*0*****Y~
Line 359: EB*G*IND*9*GP**29*0*****N~
Line 363: EB*G*IND*9*GP**29*0*****N~
Line 367: EB*G*IND*9*GP**29*0*****N~
Line 371: EB*G*IND*9*GP**29*0*****N~
Line 375: EB*G*IND*9*GP**29*0*****Y~
Line 379: EB*G*IND*9*GP**29*0*****Y~
Line 383: EB*G*IND*9*GP**29*0*****Y~
Line 387: EB*G*IND*9*GP**29*0*****Y~
While we may be speculating some, there is thought that the payer is responding with the IND line items as a result of the instructions in 1.4.9, that speaks to the patient’s portion of responsibility being “nothing” then “0” is to be placed in EB07 (or EB08). With that, what is being returned, if in fact the policy has individual coverage, is compliant with the TR3.
The payer should look at whether they are evaluating the coverage level prior to returning a response indicating that the patient has individual coverage by way of returning the EB*C and EB*G line items for IND coverage. If this patient truly is not covered under a policy that supports IND coverage, or IND coverage does not apply to this patient who is enrolled with others in his ‘FAM’ coverage, the payer should not return these EB*C*IND and EB*G*IND line items as this implies the patient has individual coverage for the benefits returned, and the deductible and out of pocket is 0. If no IND coverage is applicable to this policy or patient’s plan those line items should not be returned.
If an IND policy is applicable, and the patient’s responsibility is truly “nothing” or does not apply, “0” is appropriate and allowed.
Please note, the service type code values used in the example above (EG, EQ) are not valid for the 5010X279A1 version of the 270/271 and must not be used.
The above described solution is the preferred and most appropriate way to return the 271 for a member with a FAM only policy.
However, an alternate, yet non-preferred, way to communicate the IND policy does not apply to this member would be returning the EB01 = I (Non-covered), EB02 = IND with an EB03 = 30 (Health Benefit Plan Coverage) which will explicitly advise that IND policy is not applicable. This carries some risk as the provider may interpret the entire member’s eligibility as “non-covered.”