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EDI reporting of eligibility and benefits updated

12/15/2015

ConnectiCare will update its Electronic Data Interchange (EDI) reporting of eligibility and benefits (EB) for service type codes 96 and 98 on 271 transactions.

The new reports will display the correct copay charges for specialist and PCP visits. In the 271 EB response, ConnectiCare will use ST96 (service type 96) for a specialist copay and ST98 (service type 98) for a PCP copay.

The updated EDI 271 transaction will use the following data elements for the eligibility and benefits segments:

EB01 = B (copay indicator)
EB03 = 96/98 (service type code for professional physician visit)
EB07 = 80 (sample copay amount)

The EB segment will also include a message to accurately describe the intent of the EB segment. Below is an example of the eligibility and benefits segment with a message and copay amount in a 271 report:

EB*B**96****80~
MSG*SPECIALIST COST SHARE~
EB*B**98****50~
MSG *PCP COST SHARE~