We would appreciate clarification regarding reporting other entity/information source (e.g., carve out) for an explicit 270 eligibility request. We see that item #8 of Section 1.4.7.1 Minimum Requirements For Implementation Guide Compliance states “…the information must be returned in 2120C/D if known” but item #11 in this same section does not include the statement of ‘if known.’
Example – the 270 eligibility request is for service type code 88 – Pharmacy (i.e., EQ01=88). When the found member has active coverage and has pharmacy benefits via a separate entity (Pharmacy Benefit Manager/PBM), must the 271 response report the PBM as specified in item #11 or is this only required if the PBM information is known (i.e., PBM information is available within the benefit enrollment system)?
If the information source indicates that the pharmacy coverage is active (STC 88 in the EB03) but cannot determine in their benefit system the PBM, the other information holder would not be required to be returned.
If the information is accessible and known, the information source must return that information as outlined in 1.4.7.1, Item 6 where it states:
Other payers or plans if known in 2120C/D. (Note: Do not return details of coverage or benefits associated with other payers or plans, the Information Receiver should initiate a separate 270 request to the other payer or plan to determine the level of coverage.)
From purely a transaction validation perspective – it is difficult to validate if the information source had access to another entity’s contact information to return in the 271; while it is required ‘if known,’ the providers will not know if it is ‘known’ to know if it should have been returned or not. The housing of information that is tied to carve-outs is out of the purview of this TR3’s reach and would be dependent on the organization’s needs contracting with the carve-out(s). If an information source can determine whether they are not the true information source, the ‘if known’ is implied in Item 11 to the extent that the information source in 2000A is not able to return the answer to the benefits requested. It does not dictate how the information source identified in 2000A in the 271 houses the true information source in their system.
This TR3 governs the exchange of the 270/271 to provide eligibility and benefits information to an information receiver; however, the provider may be able to determine the eligibility and benefits from a PBM through the NCPDP exchanges they may have established.