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Back  RFI # 1001: 278 Non-EDI Response in 5010

Formal vs. Informal Help Informal Formal

Submitter

Peter Anderson

Description

Our current authorization process delivers the final responses that involve medical review via non-EDI methods (phone, fax, letter).

The 4010 IG explicitly allowed this using BHT06=18 combined with HCR01=CT (see the explanatory note on code 18 for BHT06).

The 5010 IG removed the explicit note on code 18, but implicitly allows the same combination of BHT06=18 with HCR01=CT. At least there is no explicit prohibition against this combination of permitted codes.

Did the IG authors consider the returning of a final response via the X217 to be a best practice, left to the discretion of the health plan, or a requirement?

Is the WG aware of current industry practices related to this question? If so, can they be shared in your reply?

Submitter Assigned Keywords

278 non-EDI

Response

If BHT06=18, this indicates that no addition responses will be forthcoming via EDI, however, this does not prevent the use of other means to notify the requester, if necessary. A statement of "Contact Payer" (HCR01=CT), indicates an action to be taken by the receiver, not a promise of additional action by the UMO. The message segment is one way of conveying to the requester how the response will be communicated or this information may be located in a companion guide.

The WG is aware that responses are provided in methods other than EDI when medical reviews are involved. We will clarify in the next version of the TR3 that this is an acceptable practice.
Submission 3/25/2010
Status Date 5/7/2010
Status F - Final
Primary References
Document 005010X217
Section2.5.1
Page305
Set ID278
Table1
Segment Position0100
Segment IDBHT
Element Position06
Industry NameTransaction Type Code
Code Value18