Chris,
to combine the eligibility query with a pricing query seems only logical and
in today's climate of depressed payments for providers and an adequate
self-defense mechanism.
Recently at my dentist, we checked the pricing before I went ahead to
have a crown made. Just to know that I have coverage does not mean much
since the insurer wanted to pay only $40 towards an $800 crown.
But I want to come back to my question. Could EB07 be used to relay pricing?
The IG does not necessarily prohibit this and it definetely has the
necessary data fields to tell a provider what the benefit amount for a given
procedure is.
Martin Scholl
Scholl Consulting Group, Inc.
301-924-5537 Tel
301-570-0139 Fax
[EMAIL PROTECTED]
www.SchollConsulting.com
----- Original Message -----
From: "Christopher J. Feahr, OD" <[EMAIL PROTECTED]>
To: "Martin Scholl" <[EMAIL PROTECTED]>; <[EMAIL PROTECTED]>
Sent: Saturday, May 25, 2002 8:09 PM
Subject: Re: 270/271 question
> Martin,
> It appears that what you are proposing is more of a "pricing query" than
an
> "eligibility query", an issue that we are also facing in vision care.
Most
> vision plans are structured like retail pharmacy plans, in that a set of
> complex rules exist in virtually every case that would allow the provider
> (of eyeglasses, for example) to know ahead of time not only the patient's
> co-payment (an eligibility item), but the provider's payment and contract
> "write-off" adjustment (pricing items). I understand that the Dental 837
> has a flag that permits its use as a "pricing query". Presumably, NCPDP
> supports this somehow for retail pharmacy.
>
> I don't believe the 837-P can be used in this manner.. can it? If not, it
> should probably be considered.
>
> -Chris
>
> At 08:45 AM 5/21/02 -0400, Martin Scholl wrote:
> >One of the most important tasks of insurance validation is to find out
how
> >much I get paid as a provider.
> >I am not sure how I can do this with the 270/271 transaction set.
> >For example:
> >A provider indicates in the EQ segment a Composite Medical Procedure
> >Modifier (HC:46735). He/She wants to charge $20,000 for this operation.
> >Where in the 270 would I indicate the proposed amount?
> >
> >Where in the 271 would I indicate how much a payer actually pays for
this?
> >EB07?
> >
> >Martin Scholl
> >Scholl Consulting Group, Inc.
> >301-924-5537 Tel
> >301-570-0139 Fax
> ><mailto:[EMAIL PROTECTED]>[EMAIL PROTECTED]
> >www.SchollConsulting.com
> >
>
> Christopher J. Feahr, OD
> http://visiondatastandard.org
> [EMAIL PROTECTED]
> Cell/Pager: 707-529-2268
>
