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Back  RFI # 1047: "If Not Required" Clarificatio

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Submitter

Kenneth Greenspan

Description

Looking for a clarification on these words, “If not required by this implementation guide, do not send.” If taken literally, my understanding is if the sender included the given data that is not required, then the transaction would be non compliant. For the 837P there is a clarification in section 1.12.5 of the 837P TR3 Guide which states that ‘this “do not send” statement does not establish situations where a receiver is allowed, or is required, to reject a claim” in regards to redundant data sent at the claim & line levels. I have seen 2 testing services return a HIPAA type 4 error for this situation where the place of service is the same at the claim and line level. This should not be an error, correct? The 837P (& other guides like 837I, 835, 999) also includes section 2.2.1.1 which has language pertaining to the “do not send” directive in general. I interpret this to mean that the sender is allowed to send the given data, and will be in compliance if sending this data. Could you possibly confirm this?

Submitter Assigned Keywords

If not required by this implemenation guide

Response

The intent of the Guides is that redundant claim and line information not be sent. While it is an error for the submitter to send the unneeded redundant information, section 1.12.5 clarifies that error cannot cause the receiver’s testing or validation process to reject the claim. Section 1.12.5 is not a conflict with Situational Rules that state "if not required, do not send." The intent of the authoring group is that these redundant data Situational Rules are clear and unambiguous direction to the submitter, not strict and inflexible edits that must be applied by the receiver.

Section 2.2.1.1 is a more general statement that sending data when the Situational Rule directs that the data not be sent is non-compliant with the Implementation Guide; however, the receiver is not required to reject the transaction because of that error.

Please note HIR Disclaimer below.

Recommendation

Submission 5/18/2010
Status Date 10/5/2010
Status F - Final
Primary References
Document 005010X222
Section2.2.1.1
Page55
Set ID837P