Mike,
The complex arrangments of Visits, Quantity, Dollar Amount, Percentages, Calendar
Year, Remaining, and others can create a dilema when trying to squeeze the possible
staggering variations into a receiving systems database (and still have the data make
sense). I have found that sometimes it is easiest to to parse the response into XML
which is easily incorporated into a web page for human viewing. An EB segment of
EB|C|FAM|1|||23|2000||||Y|Y|HC^99215~ can be parsed into "<EB_DISPLAY>Family
Deductible Medical Care In Network Calendar Year $ 2000.00 Authorization or
Certification Is Required Procedure Code:99215</EB_DISPLAY>" by simply addressing the
order of field display and then displaying the "definition" of each "code" received.
Your EB segment can be created in many ways. The information regarding your copays
could be represented as below, however I don't think many receiving systems will know
what to do with EB05 data.
EB*B**A4**First 6 Visits $10 Copay*23*10**VS*6~
EB*B**A4**Next 14 Visits 50% Copay*23**.5*VS*14~
B = Copay
A4 = Psychiatric
23 = Calendar Year
10 = $10.00 and .5 = 50%
VS = Visits
6 and 14 = Quantity
In addition the response could include the number remaining for the year by:
EB*B**A4**Remaining 13 Visits 50% Copay*29**.5*VS*13~
29 = Remaining
Note that EB05 is defined as:
Plan Coverage Description
A description or number that identifies the plan or coverage
Use this free-form text area to convey the specific product name for
an insurance plan.
Bob Huffman
RealMed Corporation
Indianapolis, Indiana
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Thursday, June 13, 2002 9:08 PM
To: [EMAIL PROTECTED]
Subject: Tiered Pharmacy & Other Copays
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
>
> ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
>
>
