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Back  RFI # 1190: The use of "OT" Insurance Type

Formal vs. Informal Help Informal Formal

Submitter

James Sherwood

Description

In the 2110C EB04 Page 299 and the 2110D EB04 page 403 of the ASC X12N/5010X279 TR3

Please confirm that if the responding plan is not Medicare or a Medicare Part D Administrator, OT may be used to describe another Insurance Type?

What is the use interpretation if the plan is a Medicare Part D Administrator but not responding to a Medicare Part D inquiry, such as a plan that is additionally some other type of commercial payer and needs to identify an insurance type that is not listed?

Submitter Assigned Keywords

resq911

Response

2110C/D EB04 Insurance Type Code OT “Other” only has a restricted definition of “Medicare Part D” when the Information Source in 2100A is either Medicare or a Medicare Part D Administrator. If the Information Source is not Medicare or a Medicare Part D Administrator, they may use Insurance Type Code OT when none of the other codes listed in EB04 are valid.

If the plan identified in 2100A is a Medicare Part D Administrator but not responding to a Medicare Part D inquiry, they may not use code OT to identify some other type of commercial payer. EB04 requires an insurance type code be returned if needed for subsequent transactions (see Recommend section below); otherwise it may be sent at the Information Source’s discretion.

If the 271 2100A plan is a Medicare Part D Administrator that chooses to return a value in EB04 such as for a plan that is additionally some other type of commercial payer, they must use one of the other EB04 Insurance Type Code values such as CO “Commercial”.

Recommendation

The only subsequent 005010 transactions that use the Insurance Type Code are the 837 Professional Claim 005010X222 and 837 Dental Claim 005010X224. The 837P and 837D 2000B SBR05 and 2320 SBR05 both require an insurance type code when the destination payer in loop 2010BB is Medicare and Medicare is not the Primary Payer. The only codes used in the 837P and 837D SBR05 are codes 12, 13, 14, 15, 16, 41, 42, 43 and 47.
Submission 10/29/2010
Status Date 1/3/2011
Status F - Final
Primary References
Document 005010X279
Section2712110C
Page299
Set ID271
Table2