RFI Browser

Back  RFI # 1197: How does a provider know

Formal vs. Informal Help Informal Formal

Submitter

Patrice Kuppe

Description

According to the 270 TR3: "If there is confusion as to whether the patient is a subscriber or a dependent, the transaction should be submitted with the patient as the subscriber."

Does this result in either
1. The health plan will find the dependent even if they were labeled as subscriber?
or
2. The health plan will notify the provider that the sub is really a dep and then the provider has to resubmit?

TR3: Dependent (2000D loop)
In most cases, the patient's ID card would identify if the person is uniquely identifiable
to the payer or must be associated with the subscriber. For example, if the patient is a
dependent, they are typically listed on the subscriber's ID card as dependents and do
not receive their own ID card. If there is confusion as to whether the patient is a subscriber or a dependent, the transaction should be submitted with the patient as the subscriber.

Submitter Assigned Keywords

270 Dependent

Response

The TR3 does not require health plans locate individuals sent in the incorrect location. If the individual is located in the plan's system, the plan cannot reject the transaction and require the provider to resubmit the transaction with the individual as a dependent. If the health plan chooses to look up an individual sent in the incorrect location, and they locate the individual, there are requirements outlined in section 1.4.2 Basic Concepts for Relationship to Subsequent X12 Transactions, Patient Submitted as Subscriber But Returned as Dependent, Patient Submitted as Dependent But Returned as Subscriber. Provider's systems will need to accommodate responses returned as indicated in this section.

Section 1.4.8 identifies Search Options for patients when they are known to be either the Subscriber or the Dependent. The advice given in the TR3 is intended to aid the provider if there is a lack of information available to identify if the patient is a subscriber or dependent in the plan's system.

If the individual is located in the plan's system, they are to be returned in the location that they are needed for subsequent transactions (e.g. 278, 837). Using the example in the request, the individual will be returned as a dependent and the subscriber information needed for subsequent transactions will be returned as well.

Recommendation

While the 5010 TR3 does not require health plans to locate individuals sent in the incorrect location, it is recommended that they support this function. X12N/TG2/WG1 will consider requiring health plans look for dependents sent as subscribers for a future TR3.
Submission 11/11/2010
Status Date 7/18/2011
Status F - Final
Primary References
Document 005010X279
Section1.4.8
Page25
Set ID270