TPA's are legally liable for reporting changes in eligibility to payers even when that change occurs in a prior period of coverage, but there is no facility in 834 to specify a change to a prior period of coverage without terminating coverage. The Loop 2300 DTP 349 date is interpreted as a benefit termination date even when the maintenance type is change and even though there's a Loop 2300 HD maintenance type that specifically indicates termination. There's no other DTP code to indicate a benefit change end date without termination.
Here’s an example of the kind of retroactive change that would require a benefit change begin and a benefit change end date without a termination of coverage:
Let’s say that over the course of the year, we had sent the following eligibility for a participant:
1/1/2005 – PPO coverage at single level
3/1/2005 – HMO coverage at family level
4/1/2005 – Back to PPO coverage but at family level
At this point, there’s a period from 1/1/2005 to 2/28/2005 of single PPO coverage and a period from 3/1/2005 to 3/31/2005 of family HMO coverage, and a period of 4/1/2005 and forward with family PPO coverage.
Now the employer realizes that (oops!) the employee was in a zip code that wasn’t covered for PPO coverage from 2/1/2005 to 2/28/2005, but all other periods of coverage are correct. He needed to be in HMO coverage from 2/1/2005 to 2/28/2005. Somehow we have to be able to send a change request that ONLY affects the 2/1/2005 to 2/28/2005 period without terminating the coverage entirely. Under the current spec, if we send HD*001**HMO*HMO PLAN CODE*EMP~DTP*348*20050201~DTP*349*20050228~, this will TERMINATE coverage as of 2/28/2005 instead of just changing the coverage during that period, even though the maintenance type is 001 and not 024!