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Back  RFI # 1112: OHI Interpretation in 5010

Formal vs. Informal Help Informal Formal

Submitter

Regina Haley

Description

Interpretation is requested for applying 5010X279 Sec.1.4.7.1 Minimum Requirements for IG Compliance–271, Item 6. Discussions have occurred within WG1- regarding the requirement to return COB information “if known.” Specifically when a Military Treatment Facility inquires eligibility for an active duty service member, the return of OHI is unnecessary, because TRICARE is wholly responsible for the payment of care.WG1 determined they were unwilling to change this requirement citing the desire to help facilitate commercial providers in collecting payment for services. In some cases it's possible that OHI information for non-active duty beneficiaries is known but only available on an external application/table outside the X12 messaging system. In this situation, the information is known by the information source (IS)system, but not at the “271 messaging application level.” Clarification needed as to whether the “if known” requirement applies at the IS application level or IS system” level.

Response

Section 1.4.7.1 271 requirements state “If the individual is located in the information source's system, the following must be returned:

6. Other payers or plans if known in 2120C/D. (Note: Do not return details of coverage or benefits associated with other payers or plans, the Information Receiver should initiate a separate 270 request to the other payer or plan to determine the level of coverage.)”

Based on the details in the request, the other payer information is stored in the payer’s system(s) and to comply with the requirements of section 1.4.7.1 271 Item 6, that information is required to be returned as it is “known” to the information source.
Submission 7/22/2010
Status Date 9/24/2010
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Page6
Set IDn/a