For a 271 eligibility benefit response transaction, is an information source (payer) allowed to set both the EB07 (Monetary Amount) and EB08 (Percentage as Decimal) fields in the same EB segment? The specification does not state explicitly whether this is or is not allowed. If it is allowed, could you please give a real-world example where it might be used? None of the definitions in Section 1.4.9 (Patient Responsibility) mention using both EB07 and EB08 together in the same segment.
We understand that EB07 is not used when EB01 = "A," and EB08 is not used when EB01 = "B," "C," "G," "J," or "Y." So, this question is only about other EB01 codes.
Provider organizations are writing formulas to calculate patient financial responsibility and other limits on coverage and need clarification on what combinations of fields are allowed in EB segments.
While the Standard and TR3 do not explicitly restrict the EB07 and EB08 elements from being returned on a single EB segment (aside from the limitation outlined on EB07 and EB08 presently as identified above), if an information source decides to return both in a single EB segment, it must be done with consideration given to interpretation of these elements in the response, in addition to possible provider validation software that may not accept the combination as a SNIP level 7 edit.
One such use may be when the information source wants to return that the lower of either a dollar amount or a percentage equivalent applies in certain circumstances (such as, EB01 = CB or D, a copay amount or a % of the contracted cost—whichever is lower for the service returned in EB03—would be collected by the provider from the patient), in combination with an MSG segment indicating the lower of the two financial amounts would apply. It would a best practice to include said support for the EB07 and EB08, in addition to text in the MSG segment, in a companion guide, if one is maintained, for the 271 response.