Change Request Detail
No.
1025
Date
6/15/2005
Submitter
Type of Request
Enrollment in a Health Plan
Status
DSMO Process Completed
Business Reason
TPA's are legally liable for reporting changes in eligibility to payers even when that change occurs in a prior period of coverage, but there is no facility in 834 to specify a change to a prior period of coverage without terminating coverage. The Loop 2300 DTP 349 date is interpreted as a benefit termination date even when the maintenance type is change and even though there's a Loop 2300 HD maintenance type that specifically indicates termination. There's no other DTP code to indicate a benefit change end date without termination.

Here’s an example of the kind of retroactive change that would require a benefit change begin and a benefit change end date without a termination of coverage:

Let’s say that over the course of the year, we had sent the following eligibility for a participant:
1/1/2005 – PPO coverage at single level
3/1/2005 – HMO coverage at family level
4/1/2005 – Back to PPO coverage but at family level

At this point, there’s a period from 1/1/2005 to 2/28/2005 of single PPO coverage and a period from 3/1/2005 to 3/31/2005 of family HMO coverage, and a period of 4/1/2005 and forward with family PPO coverage.

Now the employer realizes that (oops!) the employee was in a zip code that wasn’t covered for PPO coverage from 2/1/2005 to 2/28/2005, but all other periods of coverage are correct.  He needed to be in HMO coverage from 2/1/2005 to 2/28/2005.  Somehow we have to be able to send a change request that ONLY affects the 2/1/2005 to 2/28/2005 period without terminating the coverage entirely.  Under the current spec, if we send HD*001**HMO*HMO PLAN CODE*EMP~DTP*348*20050201~DTP*349*20050228~, this will TERMINATE coverage as of 2/28/2005 instead of just changing the coverage during that period, even though the maintenance type is 001 and not 024!
Suggestion
1) Allow 2300/DTP 349 to be interpreted as change end date when the 2300/HD maintenance type is change and as a term date when the maintenance type is term; or

2) Allow 2300/DTP to be R8 and allow 2300/DTP 348 to supply a range of dates so that a change period can be communicated without passing a term date; or

3) Create a new 2300/DTP code that would indicate a benefit change end date that does not terminate benefits.
DSMO Category
D
Recommendation
Disapproved. The ability to report changes in eligibility to a prior period of coverage can be handled within the existing framework without terminating existing coverage.  The loop 2300 DTP 349 date should be interpreted as a benefit termination date, since that is what the example indicates, which is the termination of a particular benefit, even though the date is changing from that was previously reported.  The example also indicates that coverage switched from PPO to HMO and then back to PPO.
Section 2.5 Termination documents the following:
  "In the case of a transfer from one coverage to another, it is necessary to terminate the old coverage and then add the new coverage. An add to a new coverage must never be assumed to result in the automatic termination of the prior coverage."
  "If the termination date is passed at the HD level for any member; the DTP segment in position 270, loop 2300; then coverage for that specific insurance product for that member will be terminated, effective on that date. Coverage for other insurance products for that member will not be affected nor will coverage for other members linked to the same subscriber."
Appeal Recommendation