OO CR-807 - Limited Coverage Policy

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Submitted by: Ken McCaslin - on behalf of ACLA Revision date: <<Revision Date>>
Submitted date: 7 August 2014 Change request ID: OO CR807
Standard/IG: Standard Artifact ID, Name: <<Artifact ID, Name>>

Issue

The proposal -

Based on a service providers catelog or Directory of Services payers may not reimburse for those services based on Diagnosis and CPT coding. This is to add a message and segments to define Limited Coverage and Permissible coverage policy requirements based on Payer. The message will be from the service provider based on their Universal Service Identifiers and will defined by Payer and the diagnosis and CPT codes, either what is permissible or what will not be reimbursed.

The problem definition and (originial) proposal can be found in the attached document. See file reference below for current version.

2014-08-26 eDOS WG reviewed with a few minor edits in the proposal (typos); updated version at: File:807.docx

Recommendation

The eDOS Work Group might be interested in moving this into v2.8.2.

Rationale

Discussion

Recommended Action Items

Resolution

OO Call 9/4/2014: edited during the call, track changes on • Motion to request this to be a v2.8.2 proposal and accept as modified Ken McCaslin, Eric Haas • further discussion: o Need to still make the changes to MCP-2 text portion o Since this includes IN4 segment need to get formal FM WG approval – or rename the segment – FM WG is meeting tomorrow, will see, if this can be on agenda o So modify to include: subject to FM WG approval o Why was this not part of original eDOS?  When ACLA was working on eDOS, there was worry, that including financial information in eDOS could send the wrong image about laboratories, BUT this is being developed through the S&I Framework eDOS WG so think that is ok in this venue Modified motion for the vote: Motion to request this to be a v2.8.2 proposal and accept as modified subject to FM WG review Abstain: 4, Against: 1 in favor: 8

WGM 9/17/2014: Was approved by eDOS, OO and FM, because it has an IN4 segment in it. Question about where to publish that segment – so consideration is to rename this segment for Payor Plan Masterfile segment to be able to publish it in the same chapter. Motion to open the CR for this discussion, Freida Hall, David Burgess, no further against:0, abstain: 0, in favor 8 Looking for a new segment name: INM – INsurance Masterfile = IMN, or PayorMasterfile1 – PM1 Motion to rename IN4 to PM1 and rename the segment to Payor Masterfile Segment Freida Hall, Francois Macary, no further discussion, against: 0, abstain: 0, in favor: 8