Group Minutes X12N TG2 WG1 September 21-25, 2008

Transcription

1 ASC X12N/TG2WG1/ Group Minutes X12N TG2 WG1 September 21-25, 2008 Chair(s) Name Company Term End Date Phone Stuart Beaton Stuart Beaton Consulting October, 2009 Ph: Donna Campbell Health Care Service Corporation January, 2009 Ph: Nadine Farmer Unisys September, 2010 Ph: om Secretary(s) Name Company Term End Date Phone Duane Guyer LabCorp Ph: Ph: Ph: Quorum Requirement Statement (please check one) This group enforces quorum requirements for group voting items. This group does not enforce quorum requirements for group voting items. X Work Products and Status (e.g. Transaction Sets, Implementation Guides, UN/CEFACT development, etc.) Work Product ID Work Product Name Work Product Status # (if applicable) 5010 X Unsolicited Eligibility and Benefit In development Roster 5010 X Health Care Eligibility and Benefit Inquiry and Response In development Next Trimester Meeting Notification Date: January 25-30, 2009 Location: Portland, Oregon Contact Person: Donna Campbell Agenda (include key items): Time Monday Tuesday Wednesday Thursday 08:00 9:30 /10:00 AM Full Insurance Full Task Grp Review and approve September 2008 (Pittsburgh) Minutes - Copy on web board Continue Pranav s Term Date discussion Discuss STC 30 s viability (homework for the group to Full Task Grp Full Insurance Tabled items from earlier in the week Agenda for next Trimester (Cincinatti) HIPAA2 Q&A, if applicable (dependent on NPRM/Final Rule state) Adjourn Revised 03/08/2004

2 ASC X12N/TG2WG1/ Group Minutes X12N TG2 WG1 September 21-25, 2008 Chair(s) Name Company Term End Date Phone Stuart Beaton Stuart Beaton Consulting October, 2009 Ph: Donna Campbell Health Care Service Corporation January, 2009 Ph: Nadine Farmer Unisys September, 2010 Ph: om Secretary(s) Name Company Term End Date Phone Duane Guyer LabCorp Ph: Ph: Ph: come up with Pros and Con s for keeping or removing) Break No breaks! No breaks! 9:30 /10:00 12:00 AM Administrative Items: (10:00-11:30) WG Conf Call Schedule October thru 2:00 pm Central for 1-1/2 hours February 6 th, March 13 th, April 20 th, May Web Board Information New Attendee/Conta ct Information Mentors (Jack and Duane), who are they, what do they can do for you! CMS Update (Ada) (15 minutes) CAQH Update (Rachel) (15 minutes) Review and approve Full Task Grp Full Insurance Management Meeting Update Continue reviewing 5050 Requirements Document If necessary, assign new items and break into sub-workgroups to continue requirements review from June. Revised 03/08/2004

3 ASC X12N/TG2WG1/ Group Minutes X12N TG2 WG1 September 21-25, 2008 Chair(s) Name Company Term End Date Phone Stuart Beaton Stuart Beaton Consulting October, 2009 Ph: Donna Campbell Health Care Service Corporation January, 2009 Ph: Nadine Farmer Unisys September, 2010 Ph: om Secretary(s) Name Company Term End Date Phone Duane Guyer LabCorp Ph: Ph: Ph: agenda/duration times for this week Roberts Rules of Order/CoChair assignments Lunch 01:00 03:00 PM Motion to Close Nominations for Co-chair position (1:00 pm) BCBSFL item for discussion. Continue reviewing 5050 Requirements Document Assign new items and break into subworkgroups to continue requirements review from June. 2:00 pm Co-Chair Election. Review Roster 1:00-4:00 If internet connectivity exists in the meeting room, otherwise, review list of changes via paper, if possible Joint Meeting with TG2/WG10 (sometime between 1-5 pm) re: external DE 1270 (aka DE 1365 (EQ01/EB03) 1:00-2:00 HSA/RTA Forum, if applicable otherwise. Continue reviewing 5050 Requirements Document If necessary, assign new items and break into sub-workgroups to continue requirements review from June. Full Task Grp Full Insurance Break No breaks No breaks! Trimester closes Revised 03/08/2004

4 ASC X12N/TG2WG1/ Group Minutes X12N TG2 WG1 September 21-25, 2008 Chair(s) Name Company Term End Date Phone Stuart Beaton Stuart Beaton Consulting October, 2009 Ph: Donna Campbell Health Care Service Corporation January, 2009 Ph: Nadine Farmer Unisys September, 2010 Ph: om Secretary(s) Name Company Term End Date Phone Duane Guyer LabCorp Ph: Ph: Ph: 03:00 5:00 PM DSMO/HIR Discussion if any 4:00-5:00 ASO for retroactive e&b inquiries (escan Data Systems) Continue reviewing 5050 Requirements Document Joint Meeting with TG2/WG10 (sometime between 1-5 pm) re: external DE 1270 (aka DE 1365 (EQ01/EB03) 3:30-5:00 Transaction Coordination Forum No meetings Elections Scheduled (include position and term dates): 1/26/2009 (Tuesday) 2:00 pm local time, Co-chair, Jan/Feb 2011 Special Meeting Notification (e.g. Interim Conference Calls, Industry Meetings, Regulatory Agency Meetings, etc.) Date: WG Conf Call Schedule October thru 2:00 pm Central for 1-1/2 hours October 6 th, 13 th, 20 th, 24 th and 27 th (24 th and 27 th are from 12:00 4:00 pm, Central) (dedicated to NPRM comments), November 3 rd, December 1 st, January 5 th Location: Conference Call Dial In: Code Contact Person: Donna Campbell Agenda: NPRM Comments, HIRs 5050/50XX requirements discussion Revised 03/08/2004

5 Executive Summary of Current Meeting (optional, but recommended): Date: September 22-25, 2008 Location: Pittsburgh, PA Summary of Major Accomplishments: New co-chair elected-nadine Farmer, Unisys Completed five changes (in concept) to 5050 (50XX) TR3. Reviewed 4 anticipated NPRM comments Discussed idea of creating language in comment format for NPRM re: Enforcement, clarifying the incentive language and the frequency of the TR3s being adopted. This comment will be distributed to the group and requested that their respective organizations enter the comments on or before 10/21. Continued Roster review. Discussed procedures for going forward. New Mentors identified (Jack H, Duane G) Elections Held (include position, term dates, and individual s name): September 23, 2008 election held, Co-chair, Term End 09/2010, Nadine Farmer Elected Time Monday Tuesday Wednesday Thursday 08:00 10:00 AM Full Insurance Full Task Grp Attend x274 Informational Forum (Urban) Full Task Grp Full Insurance Break No breaks! No breaks! 10:00 12:00 AM Administrative Items: (10:00-11:30) WG Conf Call Schedule October thru 2:00 pm Central for 1-1/2 hours October 6 th, 13 th, 20 th (NPRM comments), November 3 rd, December 1 st, January 5 th Web Board Information New Attendee/Contact Information Mentors, who are they, what do they can do for you! CMS Update (anyone) (15 minutes) CAQH Update (Rachel) (15 minutes) Approve June 2008 (New Orleans) Minutes - Copy on web board Review and approve agenda/duration times for this week Roberts Rules of Order/CoChair assignments Full Task Grp Full Insurance Management Meeting Update Review Comments and discuss responses to NPRM, if any. Continue reviewing 5050 Requirements Document If necessary, assign new items and break into sub-workgroups to continue requirements review from June. Lunch 01:00 Motion to Close Nominations for Co-chair position (1:00 pm) Review Comments and discuss responses to NPRM, if any. 1:00-2:00 HSA/RTA Forum, if applicable otherwise. Tabled items from earlier in the week Agenda for next Trimester (Portland) Adjourn Full Task Grp Full Insurance

6 03:00 PM BCBSFL item for discussion. Review Roster 1:00-4:00 If internet connectivity exists in the meeting room, otherwise, review list of changes via paper, if possible. Review Comments and discuss responses to NPRM, if any. Continue reviewing 5050 Requirements Document If necessary, assign new items and break into sub-workgroups to continue requirements review from June. 2:00 pm Co-Chair Election. Review Comments and discuss responses to NPRM, if any. Continue reviewing 5050 Requirements Document If necessary, assign new items and break into sub-workgroups to continue requirements review from June. Break No breaks No breaks! Trimester closes 03:00 5:00 PM DSMO/HIR Discussion if any 4:00-5:00 Review Comments and discuss responses to NPRM, if any. Continue reviewing 5050 Requirements Document If necessary, assign new items and break into sub-workgroups to continue requirements review from June 3:30-5:00 Transaction Coordination Forum No meetings Date and Minutes of Current Meeting Date: September 22-25, 2008 Location: Pittsburgh, PA

7 Minutes: A. Voting Items: 1. Work Products a. HealthCare Eligibility and Benefit Inquiry and Response, 5050X280> Issue Description: Explicit Requests-> Explicit Responses-expectation to return only relevant service type codes. Item 31 on BAR Motion: Stuart: Motion to approve adding language to Section that 1-7 must be returned and, ONLY relevant service type codes, not inclusive of the 30. Robert Huffman-seconded Vote Talley: Passed unanimously b. HealthCare Eligibility and Benefit Inquiry and Response, 5050X280> Issue Description: MSG segments being over used and abused. Motion: Stuart Beaton: Motion made to 1. Strengthen wording to address the correct use of the MSG segment; and 2. Add wording to reflect that replacing or repeating information already codified in another segment is prohibited. Duane Guyer-seconded Vote Talley: 21 For, 2 Against, 0 Abstentions c. HealthCare Eligibility and Benefit Inquiry and Response, 5050X280> Issue Description: Using disclaimers within the 2110C/D loops Motion: Stuart Beaton-Motion to strengthen the wording in Section to reflect the creation of a new occurrence of an EB segment when using a P (disclaimer) at the 2100C/D levels. Jack Hempel-seconded Vote Talley: 24 For, 0 Against, 1 Abstention d. HealthCare Eligibility and Benefit Inquiry and Response, 5050X280> Issue Description: Tiered benefits using EB and HSD segments Motion: Michelle Barry-Add examples to front matter to identify how to handle tiered benefits. Peter Beery -seconded Vote Talley: 23 For, 0 Against, 2 Abstentions e. HealthCare Eligibility and Benefit Inquiry and Response, 5050X280> Issue Description: Returning patient liability by Plan Motion: Stuart Beaton-Motion concerning patient liability be returned by plan. Robert Huffman-seconded Vote Talley: 20 For, 0 Against, 3 Abstentions f. HealthCare Eligibility and Benefit Inquiry and Response, 5050X280> Issue Description: Supporting past dates as the date of service on an inquiry Motion: Stuart Beaton-Motion to support a date of service within a payer s timely filing limit and not supply accumulators for a prior plan period. Robert Huffman-seconded Vote Talley: 13 For, 2 Against, 0 Abstentions g. HealthCare Eligibility and Benefit Inquiry and Response, 5050X280> Issue Description: Diagnostic Lab (EQ01=5, EB03=5) should be included in the minimum response as part of item 8 in Section Motion: Stuart Beaton-Motion to include service type code 5 to Section that is under item # 8.

8 Robert Huffman-seconded Vote Talley: 15 For, 0 Nay, 1 Abstention 2. Data Maintenance Items None a. DM #: N/A Issue Description: N/A Motion: N/A Vote Talley: N/A 3. Minutes a. June 2-5, 2008 New Orleans, LA Minutes Description: Reviewed June, 2008 New Orleans Trimester minutes Motion: Duane Guyer-Motion to approve June, 2008 trimester minutes Jack Hempel-seconded Vote Talley: Passed, 0 Against, 4 abstentions. 4. Nominations a. Co chair position-term 09/2008 to 09/2010 Description: Close nominations for 09/2008 to 09/2010 co-chair position Motion: James Sherwood-Motion to close nominations Lisa Varley-seconded Vote Talley: Passed unanimously b. Co chair position-term 09/2008 to 09/2010 Description: Open co-chair position vacated by Annie Brannan. One nominee, Nadine Farmer Nadine accepted the nomination Motion: Duane Guyer-Motion to elect Nadine Farmer by acclamation Paula Welsch-seconded Vote Talley: Passed unanimously c. Co chair position-term 01/2009 to 01/2011 Description: Open co-chair position vacated by Annie Brannan. One nominee, Nadine Farmer Nadine accepted the nomination Motion: Duane Guyer-Motion to elect Nadine Farmer by acclamation Paula Welsch-seconded Vote Talley: Passed unanimously B. Key Discussion Items 1. Unsolicited Roster, 5010X205 a. Discussion: How do we manage updating the Roster when it s evident OnlyConnect is accessible via internet and internet is not available in the meeting rooms? b. Decisions: Have the WG work off the paper.pdf and have the designated subworkgroup members update using comments. Assign those subworkgroup members segments to allow for consistency when applying comments. 2. Management Meeting Update a. Discussion: Reviewed WG21 s plans for NPRM process and it s procedures for X12N TGs and WGs. Discussion regarding Full N and Full TG2s Monday morning sessions start/end times. Workgroup asked whether we should continue to meet at 10, or change start time to 9:30 am on Mondays. b. Decisions: Start time will be 9:30 am on Mondays 3. BCBS Florida Non-Traditional Benefits

9 a. Discussion: Reviewed BCBSFL s scenario for non-traditional plans where benefits are paid based on benefit periods that fall outside of and are separate from contracts usual/customary calendar/service year arrangements Florida requested consideration to add codes to EB06 for Benefit Period, and DTP01 for Benefit Period Begin(Start) and Benefit Period End. WG/Co-chairs suggested that DTP can be handled today using Benefit Begin/Benefit End, or Period Start/Period End in 2110C. WG/Cochairs suggested BCBSFL discuss with TG8 and enter a CMR based on that discussion. b. Decisions: BCBSFL will readdress with WG1 after discussion with Business/Technical leads at BCBSFL and further discussion, if needed, with TG8. C. Informational Forum Notes None 1. Forum Details N/A a. Date/Time b. Title/Topic 2. Forum Notes D. Joint Meeting Notes None 1. Meeting Details N/A a. Date/Time b. Title/Topic c. Participants 2. Meeting Notes E. Other Notes 1. Detailed meeting Notes: Monday, September 22, The Monday morning Work Group 1 session was called to order by Annie Brannan at 10:00 am. Co-chairs in attendance were Donna Campbell and Annie Brannan. Stuart Beaton arrived early afternoon.. Work Group 1 introductions were made. Work Group 1 administrative items reviewed. New members were recognized. Co-chair, Donna Campbell, reviewed how to gain access to the Work Group 1 webboard ( Donna Campbell provided Work Group 1 with the web address for Stuart Beaton (stuart@ com) Review of conference calls for Work Group 1. Current Work Group 1 mentors were identified. Dave Foulke Heartland Nancy Sloan-Wellpoint New Work Group 1 mentors appointed. Jack Hempel Group Health Duane Guyer LabCorp CMS Update. Eligibility batch processing. Still in discussion. Claims readiness by 10/2009. Eligibility readiness by 10/2009.

10 CAQH Update. Postponed until Tuesday afternoon session due to Rachel attending other work groups. Review of Agenda for September conference. The approval of the June conference minutes will be done after review by WG1 members. Nominations for co-chair position coming open. 271 Roster review 50-Next Business Requirements continuation Elections for co-chair on Tuesday at 2:00 pm. Review of Lunch and Learns for the September conference. Info Forum at 9:00 Tuesday in URBAN. WG1 will not meet until 1:00 pm Tuesday to allow members to attend the Info Forum at 9:00 am. Full TG2 will meet at 10:00 am Tuesday. Full N will meet at 11:00 am Tuesday. Donna Campbell reviewed how Work Group 1 follows Roberts Rules of Order Donna Campbell reviewed WG1 procedures for discussions (co-chair responsibilities) End of Administrative Items. Presentation BCBS of Florida (Michelle presenter) Trying to reduce cost and provide better information in 271 responses. Discussion of contract date versus first use of benefit date. Provider perspective of providing true effective date of coverage with plan. Guidance from co-chair to generate CMR to be sent down to WG1 for 50-Next Examples to be provided during Monday afternoon s session. Discussion to continue Monday afternoon. Business Requirements Review for Next Version. Review of group assignments. Assigning of remaining items to be discussed and resolved for 50-next Develop front matter write up for assigning business financial responsibility (patient liability) Tiered benefits 271 response from payer to provider with applicable information (explicit requests/responses) AAA code expansion Website (non EDI) information versus 270/271 transaction source information The Monday morning session was adjourned at 11:30 am. Lunch break and RTA Info Forum. Monday Afternoon Session reconvened at 1:00 pm. Co-chairs in attendance were Stuart Beaton, Donna Campbell, and Annie Brannan. Nominations for Annie Brannan s co-chair position. Motion made to close nominations. James Sherwood Motion seconded. Lisa Varley Co-chair put motion to vote. Donna Campbell WG1 voted and passed unanimously with no abstentions and no nays. Review of 271 Roster for Version Discussion to determine how to design roster. Discussion of product used in development of roster. Discussion concerning segments and comments to remove.

11 Discussion of how to develop the roster file to meet all business needs. Donna Campbell will work with WPC to streamline how to update guide with members of subworkgroup. Possibly update.pdf and later update OnlyConnect. Review of V5010X279 Comments from EDS/DOD. Reviewed comment from Defense Manpower Data Center (Gary Yager) concerning the requirement to provide other insurance information for coordination of benefits on eligibility responses. Discussion by Work Group 1 members. Co-chairs responded that the TR3 reflected the intent of the transaction guide was to have payers respond correctly based on adjudication and payments of claims. Reviewed comment from Defense Manpower Data Center (Gary Yager) concerning the requirement the impact of providing information from the prior comment to the real-time environment. Work Group 1 members discussed. Co-chairs responded concerning the intent of the TR3 guidelines and the impact to payers and claim adjudication. Reviewed comment from Defense Manpower Data Center (Gary Yager) concerning eligibility response format for a dependent who can be uniquely identified by a health plan. Discussion by Work Group 1 members. Cochairs responded with information concerning how eligibility should coordinate responses with claims. Reviewed comment from Defense Manpower Data Center (Gary Yager) concerning the 999 Implementation Acknowledgement which is not a HIPAA requirement. Discussion by Work Group1 followed. Co-chairs explained how the 999 transaction is more robust than the 997. Afternoon break. 2:45 to 3:00pm Review of Item #31 from 50-Next Business Requirements. Explicit Service Type Codes. A discussion concerning the guidelines for payers to return information pertaining to listed service type codes was led by co-chair Stuart Beaton. The discussion covered whether to require payers to respond to certain explicit service type codes, require payers to response to all explicit codes, leave guidelines as they are to require payers to respond to a service type of 30. The discussion lasted for the remainder of the afternoon with many members speaking to this issue. Tuesday, September 23, 2008 Session. Afternoon session was called to order at 1:00 pm. 40 persons were in attendance. Co-chairs present Donna Campbell and Annie Brannan. Co-chair Donna Campbell called on Rachel Foerster for the CAQH/CORE update. Rachel provided a current status of Phase II progress. Work Group 1 introductions were made. Donna reviewed the remainder of the agenda for the Tuesday afternoon session. Election for the co-chair position vacated by Annie Brannan at 2:00 pm. Work Group 1 teams for Business Requirements for the 50-Next TR3. Donna Campbell called on Michelle Barry for a presentation concerning coverage effective dates. Michelle Barry presented information to obtain guidance from WG1 co-chairs. How to provide coverage benefit periods in the EB segments. Issues with using existing codes or try to create additional codes.

12 The discussion for the contact period code was stopped to allow Work Group 1 to vote for the co-chair position. Debbi Meisner, co-chair for TG2, took over the election. Nadine Farmer was recognized as the only nominee for the co-chair position. A motion was made to elect Nadine for the co-chair position by acclamation by Duane Guyer. Paula Welsch seconded the motion. Debbi put the motion to a vote by Work Group 1. Work Group 1 voted and the motion was passed unanimously. Debbi closed the election. Work Group 1 continued to discuss the EB segment issue for contract period. Co-chairs, Stuart Beaton and Donna Campbell, suggested Michelle generate a CMR to propose adding a new code for contract period code in the EB06 field. In addition, Donna and Stuart suggested the code values to identify the start/end or begin/end dates were already available in DTP01. Donna suggested Michelle speak with TG8 cochairs and the adding of benefit period to the EB06 (if available in the standard). Michelle will first discuss with her respective BCBSFL parties and will thereafter determine the need to follow up with TG8/CMR. The discussion was concluded. Annie Brannan made a motion to open nominations for the co-chair position currently held by Donna Campbell. Stuart Beaton seconded the motion. Stuart Beaton nominated Donna Campbell. There were no further nominations made. Afternoon Break 2:15 to 2:30 pm. The afternoon session resumed after the break with Work Group 1 breaking up into smaller work groups to work on and resolve business requirement issues in the 50-Next version. The afternoon session concluded at 5:00 PM. Work Group 1 will resume at 10:00 am Wednesday morning. Wednesday, September 24, The morning session was called to order by Donna Campbell at 10:00 am. Co-chairs present were Donna Campbell and Nadine Farmer. Stuart Beaton arrived at 10:20 am. (Donna won the bet.) Donna Campbell asked Nadine Farmer to review the Management Meeting. Nadine provided information from the meeting. All comments must be sent to DHHS by 5:00 pm EDST on October 21st. X12 has 5 business days to respond to all technical comments for Donna explained how the comments and responses would be manipulated internally. Donna explained how comments would be summarized by DHHS if they were similar and be responded to once. Donna explained that some transactions would not have X12 technical responses to comments such as the 999 transaction. Nadine explained that the reason the industry had to go to version 5010 was to accommodate the ICD10 version. Donna discussed the changes to the Monday morning meetings for N and TG2. Donna took a vote to see if WG1 wanted to begin at 9:30 am on Monday s after N and TG2. WG1 voted unanimously to have Monday morning sessions begin at 9:30 am. Donna led the group in a review of the June 2008 trimester conference minutes. Donna called for any

13 amendments. Duane Guyer made a motion to approve the minutes from the June 2008 conference. Jack Hempel made a second to the motion. Donna called for a vote. The vote was taken and the minutes were approved with 4 abstentions. There were no nay votes. Work Group 1 resumed the review of results of the 50-Next business requirements from the different team groups. The team working on item #36 reported their results. The team working on item #35 reported their results. Work Group 1 broke for lunch from 12:00 to 1:00 pm. Work Group 1 reconvened at 1:00 pm. Co-chairs present were Stuart Beaton, Donna Campbell, and Nadine Farmer. Work Group 1 resumed the review of results of the 50-Next business requirements from the different work teams. The team working on item #35 continued its report on their results. A discussion ensued on the use/misuse of the MSG segment when the information in the segment repeats codified information already provided or is used in place of codified options, but never brought to X12 to create a code to use. Stuart presented a motion to address the MSG segment situation. There are two parts to this motion. 1) Strengthen wording to address the correct use of the MSG segment. 2) Add wording to reflect that replacing or repeating information already codified in another segment of the transaction is not allowed (or prohibited). Duane Guyer seconded the motion. Work Group 1 members further discussed the motion. Stuart called for further discussion. There was none. Donna Campbell called for the vote. There were 21 For, 2 Against, No abstentions. Stuart presented a motion to strengthen the wording in Section to reflect the creation of a new occurrence of an EB segment when using a P code at the 2100C and 2100D levels. Jack Hempel seconded the motion. A discussion followed of the motion. Donna Campbell called for a vote by Work Group 1. There were 24 for, none opposed, and 1 abstention. The motion passed. The team working on item #4 (Tiered Benefits) on the 50-Next business requirements reported their results. After review of the examples provided, a motion was made by Michelle Barry to use the examples for tiered benefits in the 50-Next TR3. Peter Beery seconded the motion. There was no discussion on the motion. Donna Campbell called for a vote on the motion. The motion passed with 23 for, none against, and 2 abstentions. Stuart Beaton led Work Group 1 in a further discussion of tiered benefits. Stuart Beaton made a motion concerning patient liability be returned by plan. Bob Huffman seconded motion. Donna Campbell called for the vote. There were 20 for, none against, and 3 abstentions. The motion passed. Work Group 1 broke for the Info Forum on HIPAA transaction information scheduled at 3:30 pm. Work Group 1 will reconvene at 9:00 am Thursday, September 25th. Thursday, September 25, The morning session was called to order at 9:15 am by Donna Campbell. Co-chairs present were Donna Campbell. Stuart Beaton arrived at 9:33 am.

14 Work Group 1 recognized Pranav Shah having his 32nd birthday. Donna led the work group in a discussion concerning the review of remaining business requirements to be reviewed. The items for accumulators and future dating was (2 separate items) still outstanding as of last meeting. After reviewing the minutes, it was determined that the accumulator items in question were addressed and voted on in the New Orleans June conference. A motion was made, by Bob Huffman, to accept the workflow diagram as presented by Donna Campbell. Donna Campbell seconded the motion. There was no discussion. The vote was taken and it was passed unanimously. The co-chairs will present the diagram to TG2 and other X12 management when a lighter moment is needed. Stuart led the work group in a discussion concerning explicit responses. Stuart presented the following examples for the group to follow and use for discussion. Type 1 New or existing patient, prior to visit generic Type 2 Detailed service type code request prior to or at visit Type 3 Detailed procedure code/diagnosis code prior or at visit Type 4 Post visit determination of eligibility (could be retroactive) Type 1 Generic Request Service type code 30, respond with the 10+ Type 2 Explicit Request Explicit Service type codes, explicit request, respond with only relevant service Section items 1-7 All service type codes, explicit request, respond with only relevant service type EB01: 1 thru 5 (Active coverages) I (non-covered) CB (coverage basis extenuating circumstances with another EB01 = U / contact / And PER with phone and possibly a URL EB03 = submitted service type code Additional EB s with relevant service type codes may also be sent Type 3 Not required. Functionality exists today. Type 4 Type 1 and Type 4 are similar, except the dates (Type 1 future/current date, Type 4 is past) Stuart Beaton made a motion to approve adding a new section in the front matter regarding explicit requests for the 50-Next TR3 for all service type codes except for the existing service type of 30. (Refer to Stuart s document.donna). Bob Huffman seconded the motion. Donna called for the vote. Work Group 1 voted unanimously to accept the motion. There were no nay votes and no abstentions. There was a discussion concerning the continued use of the service type of 30. Donna suggested that the group provided pros and cons concerning the service type of 30 over the next four months and discuss this issues at the January 2009 conference. This issue will be table until then.

15 Stuart Beaton made a motion to include the service 5 to section that is under item #8. Bob Huffman seconded the motion. Donna Campbell called for the vote. There were 15 for, none against, and 1 abstention. A discussion followed concerning how payers should respond to eligibility requests using dates in prior benefit periods (years). Special concern was voiced about accumulators being returned for past DOS inquiries. Stuart Beaton made a motion to support a date of service within the responding payer s timely filing limit and not supply accumulators for a prior plan period. Bob Huffman seconded the motion. Donna called for discussion. There was none. Donna called for a vote. There were 13 for, 2 against, and no abstentions. The morning session was adjourned at noon. Pranav provided these examples: Benefit: Active EB01=1-5 Inactive EB01 = 6-8 Never Active EB01 = I Return DTP/291 or 346 DTP/ or No DTP Pranav s DTP examples will be tabled until the Portland conference in January. There was a discussion concerning accumulators and the impact of passing future dates led by Michelle Barry. The concerns with how to pass future dates were addressed in a prior conference meeting. Donna Campbell suggested that Paula Welsch review and ensure that the accumulator item resolutions contain directions on passing future and past dates involved with accumulators. Further discussion will be needed to craft language to be put into the 50-Next version. Action Items (when applicable) Action Item Responsible Party(ies) Due Date (when applicable) Post Agenda for Portland, OR Donna 10/2008 Post Draft 5010 E&B Roster Donna 01/2009 Post Draft 5050 E&B I/R Stuart 01/2009 Pranav s DTP discussion (example above) All 01/2009 EQ 30 discussion All 01/2009 Completed Date

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17 Change tracking - Benefit Analysis/Business Justifications for change Solution Inform Tracking Number Problem statement or New Business Function Problem Consequence New Function Benefit Solution Description Version/Release Loop 1 Financial Liability Providers need information relative to what the patient's liability responsibility is. Generic contract level information still does not answer the information. Require both contract level a/o accumulator level amounts be returned. These could be both financial ($) and non financial (visits/days, etc) Financial liability would be required to be returned; additionally, accumulators would be required as well. Update front matter to include requirement that payers return financial liabilitycoinsurance, deductible, copay, out of pocket/stop loss, cost containment and spend down if and where applicable. Additionally, language will be added to require accumulators be returned specific to financial and nonfinancial amounts (days/visits, etc) 5050 N/A

18 4 Tiered Benefits Tiered Benefits are a pre-service way of identifying tiered benefit structures. Update front matter with examples of tiered benefits when it cannot be determined which tier the individual is in. Examples would help standardize how tiered benefits would be reported. Update front matter to include new language and examples identifying usages of EB and HSD for tiered benefits 5050 N/A 14 Accumulators Part 1($) Providers need information relative to what the patient's liability responsibility is. Generic contract level information still does not answer the information. Require both contract level a/o accumulator level amounts be returned. These could be both financial ($) and non financial (visits/days, etc) Financial liability would be required to be returned; additionally, accumulators would be required as well. Update front matter to include requirement that payers return financial liabilitycoinsurance, deductible, copay, out of pocket/stop loss, cost containment and spend down if and where applicable. Additionally, language will be added to require accumulators be returned specific to financial and nonfinancial amounts (days/visits, etc) 5050 N/A

19 21 Identify the number of family members that need to meet their individual deductibles before the family deductible is considered met. Example: 2 individual deductible must be met EB*C*FAM********NP* 2~ DE 673 code np = no. of members EB*C*FAM******** Explicit Request, what s required on the response. (we have 10 service type codes, haven t required a plan to support anything other than a generic inquiry. Require payers support an explicit request. Adding language to return financial liability, and accumulators, and other required information) Often, deductibles are set at individual limits, and family deductibles are based on a number of family members that must meet an individual deductible to satisfy the family deductible. This concept is not available to implement currently and requires the MSG segment to address. The transaction can be overly robust and does not require explicit responses when a provider submits an explicit request. Rather some payers will return responses for the 30 "generic" request, and then not support those STCs on the generic request when they are submitted explicitly. All code values and language to identify how to identify Person based deductibles. This would require payers to support the explicit requests, sizing down the transaction and narrowing in on the question/answer. Add "NP" code value to DE 673; allow EB01=C to be sent without EB08=$ Add language in front matter identifying explicit request/response requirements C/D 5050 N/A

20 35 MSG segment usages Overuse of the MSG segments has show the transaction is lengthy and size prohibitive. Providers have to weed thru MSG segments to read information that could or should be codified. X12 has not been receiving requests to add code values, so the request to use the MSG segment as a temporary solution is being abused. Add language to tighten up the usage requirements and strengthen the message of using it temporarily, in addition to requesting codes be added. Add language in front matter and on MSG segment C/D 37 Identify term dates on inactive status responses when term date is in past, or DOS is before plan begin date. 40 Support past/future dates**, and how far back/forward must be supported(?) **might be some Medicare(A/B) issues due to never active scenarios Providers have explained that inactive/term dates are important for retro billing and retro eligibility verifications. Providers have retrobilling practices that require past DOS eligibility/benefit verification. Add language to require term dates be returned in certain scenarios (TBD). Add language to require a payer support eligibility inquiries as consistent with timely filing requirements. (accumulators would not be returned on past dated E&B inquiries) Add language in front matter identifying date requirements. Add language in front matter identifying date requirements N/A 5050 N/A

21 42 Identify Diagnostic Lab benefits as part of the Generic Response, as well as supported in the explicit request response. Diagnositc Lab benefits are a large portion of a benefit plan, but the benefits are not currently required to be returned as part of a generic request/response. Also, since explicit service type code support is also now required, diagnostic lab benefits should be included in those requirements as well. Add code Service Type Code 5 - Laboratory to section items 8 and 9. Add code 5 to language to the explicit request language (item 31). Add language in front matter identifying Diagnostic Lab requirements for both generic and explicit request/responses N/A