Draft Website - For Review Purposes Only

The Technical Steward for the PM1 segment is Orders and Observations.

For the payer defined in PM1-1 and the service provider defined in MFE-4:

• When MFI-1 is MLCP (Medical Limited Coverage Process) this segment is identifing what is in limited coverage.

• When MFI-1 is MACP (Medical Approved Coverage Process) this segment is identifing what is approved. This segment defines the tests that are approved for a given Diagnosis Code based on the Procedure Code.

HL7 Attribute Table - MCP - Master File Coverage Policy Segment

Seq#	DataElement	Description	Must Implement	Flags	Cardinality	Length	C.LEN	Vocabulary	DataType
MCP
1	03468	Set ID - MCP	SHALL		[1..1]	[1..4]			SI
2	00587	Producer's Service/Test/Observation ID	SHALL		[1..1]			0630	CWE
3	03469	Universal Service Price Range – Low Value			[0..1]				MO
4	03470	Universal Service Price Range – High Value			[0..1]				MO
5	03471	Reason for Universal Service Cost Range	MAY True: False:	C	[1..1] [0..1]				ST

Definition: MCP-1 - set ID - MCP contains the number that identifies this transaction. For the first occurrence the sequence number shall be 1, for the second occurrence it shall be 2, etc. The Set ID in the MCP segment is used to uniquely identify the segment. There are likely multiple instances of Universal Service Identifier, Diagnosis and Procedure code.

(Definition from OM1.2 in Ch. 8)

Definition: This field contains the producer's usual or preferred identification of the test or observation. Only three components should be included: <ID code>^<service text name/description>^<source list of code>. All components should be non-null. Refer to Table 0630 - Producer's Service/Test/Observation ID in Chapter 2C for valid values.

(Definition from MCP.2 in Ch. 8)

Definition: This field contains the producer's usual or preferred identification of the test or observation. Only three components should be included: <ID code>^<service text name/description>^<source list of code>. All components should be non-null.

Definition: Specifies the lowest price for the Universal Service that needs to be disclosed on the payer notification to the patient (for example Medicare ABN). If there is a single price for this Universal Service Identifier, MCP-3 is not valued.

Example:

MCP|||35.00^USD|75.00^USD

Definition: Specifies the highest price for the Universal Service that needs to be disclosed on the payer notification to the patient (for example Medicare ABN). If there is a single price for this Universal Service Identifier, it is valued in this field.

Example of MCP-4 where price of test is $65.00 and there are no variants to the cost:

MCP||||65.00^USD

Example of MCP-3 and MCP-4 value when the price of test is variable and can range from $35.00 (low) to $75.00 (high):

MCP||||$35.00^USD|75.00^USD

Definition: Specifies the reason for the interval between the lowest and the highest price for the Universal Service, for example additional testing (reflex test) that is added based on values of the initial test. There maybe some instances when the value between MCP-3 and MCP-4 is not significant enough to warrant a reason as defined by health authorities.

Condition: This is conditionally required when MCP-3 is valued.