Change Request Detail
No.
1139
Date
2/3/2011
Submitter
Type of Request
Health Care Eligibility Requests or Responses
Status
DSMO Process Completed
Business Reason
New Codes and/or New Data Elements Needed to Minimize Use of the MSG Segment in the 271 Transaction
Suggestion
I.    Add New Codes

EB01 - Elibility or Benefit Information Code - DE 1390:
Pay as any Other Illness;
Pay as Prescription Drugs;
Subject to Contract Limitations;

EB02 Coverage Level Code DE 1207:
Additional Spousal Deductible;
Per Adult;
Per Eligible Beneficiary;
Per Employee or Retiree;
Per Female;
Per Health Start Program Enrollee;
Per Individual Spouse or Dependent;
Per Male;
Per Priest;
Per Retiree;
Per Single Contract;
Upfront Family;
Employee More than 15 Years Service;
Per Subscriber Less than 10 Years Service;
Per Subscriber More than 10 Years Service;

EB03 Industry Code DE 1271
(Requested from the Claim Adjustment Status Code Maintenance Committee):
Facility Services;
Accidental Injury;
STD;
Facility;
Emergency Room;
Medical and Drug;
Professional Services with Urgent Care Visit;
Medication Management;
Facility Ancillaries;
Take Home Drugs;
Allergy Serum;
Allergy Injections;
Genetic Counseling;
Crisis Services;
Interpretation Services;
Professional Therapy;
Specialist Office Visit;
Overall;

EB04 Insurance Type Code DE 1336:
Medicare Advantage Local PPO;
Medicare Advantage Regional PPO;

EB09 Quantity Qualifier DE 673:
Aggregate;
Deductible Included in Out-of-Pocket (OOP);
Liabilities Cease after Out-of-Pocket (OOP) is met;
Family Deductible is met when Two Individual Deductibles are met;
Family Deductible is met when Three Individual Deductibles are met;
Family Deductible is met when One Individual Deductible is met and Aggregate Deductible is met;
Birth to 28 days;
Age 6 months and younger;
Age 7 months to 18 months;
Age 9 months to 12 months;
Age 12 months to 24 months;
Age 18 months to 7 years;
Age 24 months to 6 years;
Age 1 year to 2 years;
Age 1 year to 3 years;
Age 1 year to 6 years;
Age 2 years to 12 Years;
Age 2 years to 13 years;
Age 2 years to 19 years;
Age 3 years to 4 years;
Age 3 years to 7 years;
Age 4 years to 5 years;
Age 5 years to 6 years;
Age 6 years to 18 years;
Age 6 years to 19 years;
Age 6 years to 23 years;
Age 18 years to 40 years;
Age 18 years to 50 years;
Age 19 years to 39 years;
Age 35 years to 40 years;
Age 40 years to 50 years;
Age 40 years to 64 years;
Age 45 years to 50 years;
Age 50 years to 60 years;
        
II.    Add New Segment IDs and Codes
                    
New Segment ID EB?? Network Type Code:
All Networks;
Extended Network;
In-Network;
Out-of-Network;
Non-Participating;

New Segment ID EB?? Text Field -
A description that identifies a unique provider network related to the Network Type Code contained in the previous segment ID as per the examples below:
Blue Distinction;
Blue Select Chiropractic;

New Segment ID EB?? Contract Level Code:
Base;
Major Medical;
Supplemental Medical;

New Segment ID EB?? Multiple Amounts or Limits -
When more than one amount or limit applies to the total amount or limit of coverage.  See common Mental Health legislation example below:
Level 1 Ex: First 10 hours paid at 80%;
Level 1 Ex: Next 30 hours paid at 75%;
Level 1 Ex:
Level 1 Ex:
DSMO Category
D
Recommendation
Disapprove. This is a request to add codes to the external code set. Please see
http://www.wpc-edi.com/content/view/996/1 for more information.
The FAQs on the left-hand menu pane provide information on submitting requests for new codes.
II. This is a request to add codes to the ASC X12 standard. Please see

http://www.x12.org/x12org/X12Standards/CMR/SubmitterInformation.cfm for more information.

All code request submissions must include business justification with the request.

Appeal Recommendation