This issue applies to us as well. We are also trying to determine how to show psych benefits when the first 6 visits may be a $10.00 copay, then the next 14 are 50% copy.
Mike Turner [EMAIL PROTECTED] (716) 887-8769 Office (716) 887-7008 Fax ------------------( Forwarded letter 1 follows )-------------------- Date: Wed, 12 Jun 2002 10:05:19 -0500 To: Cynthia.Korman[ckorman]@healthcare-systems.com, [EMAIL PROTECTED] From: Tammy.Neumeister[tneumeister]@mhsjvl.org Sender: [EMAIL PROTECTED] Subject: RE: Tiered Pharmacy Our health plan also has the same issue. We also have a three tier program consisting of: Generic Preferred Brand Non Preferred Brand We could be added to the list of health plans needing this change. I agree that the more plans that show a need for this change, the better the chance of getting it accomplished. Tammy Neumeister SAS Programmer MercyCare Insurance Company PO Box 2770 Janesville, WI 53547-2770 800-752-3431 X 3068 Direct 608-758-7725 Fax 608-752-3751 [EMAIL PROTECTED] > -----Original Message----- > From: Cynthia Korman [SMTP:[EMAIL PROTECTED]] > Sent: Wednesday, June 12, 2002 9:27 AM > To: [EMAIL PROTECTED] > Subject: Fw: Tiered Pharmacy > > Three-tier pharmacy co-pays seem to be a trend across payers...Sean, do > you > have any contacts at other health plans, to see how they're handling this? > > I'd think it's a good idea to propose a logical change to x12 (unless x12 > has already developed an accommodation), but proposed change should come > from at least several health plans...perhaps you plus two can agree on a > design and then > propose, plus have a temporary modus operendi...pls contact me off-list if > you need some contacts, I may be able to help... > > Cynthia Korman > [EMAIL PROTECTED] > ----- Original Message ----- > From: "Robert Huffman" <[EMAIL PROTECTED]> > To: "September, Sean A B230" <[EMAIL PROTECTED]>; > <[EMAIL PROTECTED]> > Sent: Wednesday, June 12, 2002 8:29 AM > Subject: RE: Tiered Pharmacy > > > Good morning Sean, > > September is one of my favorite months. > > You have stumbled down the same path I have been on for the last couple of > months. As I have worked with several major payer organizations I have > discovered an entire realm of copays that I never envisioned ranging from > "Electroshock Therapy" to "IV Therapy" that simply do not map to any EB03 > service type codes. > > To quote Rachel Foerster "Where the heartburn is: the Semantic Alignment > of > Business Data", the process of mapping revolves around the actual meaning > of > data. Data is stored somewhere that has specific business meanings, that > information is sent using EDI X12 standards and code sets, elsewhere that > data is read and hopefully the same business meaning is derived by the > receiver. > > Back to your specific problem. > The first one is easy: EB*B*92**27*5**VS*1~ > The next two cannot be defined, what is the business meaning behind > "Preferred" and "Non-preferred"? If there is no EB03 service type code > for > those two business types, then you have two choices. First, let X12 know > that they may have missed a few copay codes and hopefully have them added > to > the code sets to be used "eventually". Second, change your system to > accommodate the strict set of codes available in X12. > > Sometimes you can't get there from here! > > Bob Huffman > RealMed Corporation > Indianapolis, Indiana > > > -----Original Message----- > From: September, Sean A B230 [mailto:[EMAIL PROTECTED]] > Sent: Wednesday, June 12, 2002 6:22 AM > To: '[EMAIL PROTECTED]' > Subject: Tiered Pharmacy > > > Hello, I am currently working on the 270/271 HIPAA transaction set. I am > attempting to display/map tiered pharmacy copayments/coinsurance amounts. > For example: > > * Generic $5.00 > * Preferred $10.00 > * Non-preferred $15.00 > > The Service Type Codes (EB03) available are: > * 88 = Pharmacy > * 91 = Brand Name Prescription Drug > * 92 = Generic Prescription Drug > and for Mail order: > * 90 = Mail Order Prescription Drug. > > > I am finding it difficult to accommodate for the tiered pharmacy > copayments/coinsurance. Is anyone else experiencing this dilemma and is > there a solution? > > Your suggestions and assistance is appreciated. > > Sean A. September > E-mail [EMAIL PROTECTED] <mailto:[EMAIL PROTECTED]> > > > -------------------------------------------------------------------------- > -- > -- > CONFIDENTIALITY NOTICE: If you have received this e-mail in error, please > immediately notify the sender by e-mail at the address shown. This e-mail > transmission may contain confidential information. This information is > intended only for the use of the individual(s) or entity to whom it is > intended even if addressed incorrectly. Please delete it from your files > if > you are not the intended recipient. Thank you for your compliance. > Copyright (c) 2002 CIGNA > > ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ > >
