Question

1. you run the eligibility benefit filing copay report and receive the following data:

what action would the system take based on the information that returns in this msg? choose only one answer.

a. it matches on the first mapping and will file to service in the ed ecd
b. it matches on the second mapping and will not file
c. no match is found so it will file to service in the ed ecd
d. there is not enough information in the report to determine what the system will do.

Explanation:

Analyze the incoming data from the report

The report data shows:

• Benefit Code (EB01): Co-Payment [8]
• Service Type (EB03): Emergency Services [86]
• Message Text (MSG01): "MAXIMUM SAVINGS"
• Circled key values at the top: "86, Y, MAXIMUM SAVINGS"

Evaluate the first mapping block

• The first mapping block is for "Benefit filing mappings for Emergency Services [86]".
• Match action: "File to service - ED [2]"
• MSG segment handling: "No MSG Segment" is selected (highlighted in blue).
• Since "No MSG Segment" is selected, this mapping matches if there is no MSG segment returned in the response. However, the incoming data contains an MSG segment with the text "MAXIMUM SAVINGS". Therefore, the first mapping does not match.

Evaluate the second mapping block

• Match action: "Do not file"
• MSG segment handling: "Custom MSG Logic" is selected (highlighted in blue).
• Defined MSG search logic: "ANCILLARIES" OR "ANESTHESIA"
• The incoming MSG text is "MAXIMUM SAVINGS", which does not contain "ANCILLARIES" or "ANESTHESIA". Therefore, the second mapping does not match.

Evaluate the fallback action

• Since neither the first nor the second mapping matches, the system falls back to the "No match found" action.
• The "No match found" configuration is set to: "File to service - ED [2]".
• Therefore, no match is found, and the system will file to service in the ED ECD.

Answer:

• (A) It matches on the first mapping and will File to service in the ED ECD
• (B) It matches on the second mapping and will not file
• (C) No match is found so it will File to service in the ED ECD (Correct answer)
• (D) There is not enough information in the report to determine what the system will do