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Back  RFI # 1293: EDI Primary Search Option

Formal vs. Informal Help Informal Formal

Submitter

Nancy Jeglic

Description

The front matter of the TR3 for the EDI 270/271 transaction, section 1.4.8.1, indicates that if all four of these elements (member ID, first name, last name, and date of birth) are present on the 270, the information source must generate a response if the patient is in their database.

If all 4 are submitted along with additional data elements (such as Group number, Social Security Number, or Address) are the 4 primary elements plus the additional data elements to be used to search? Or are the additional elements supposed to be ignored so that the information source's database is searched with only the member ID, first name, last name, and date of birth?

Response

If all four pieces of the primary search option identified in Section 1.4.8.1 are sent, the information source is required to support searching for the member. They may use all pieces, a single piece or a combination of the four but they must generate a response (basically the member is found or not found). The primary search option is the maximum data set an Information Source can require that an information receiver submit on a 270. It has no relevance on what the provider may additionally submit nor does it dictate an order by which the information source must search using the primary search option data elements or any other elements submitted.

Additional information sent in the 270 can be used to locate a unique match in the information source’s system, but cannot be required by the information source in a 270. As noted in the Note Section of 1.4.8.5, the information that was used from the 270 to locate the member in the information source’s system must be returned on the 271.

Recommendation

Section 1.4.8 outlines the maximum data set an information source can require for each of the required search options and encourages providers to send whatever patient information they have on hand to identify them to the information source.

Information Sources are encouraged to continue searching for a patient with any additional data submitted by the provider should they not be able to locate the patient with the items from the primary search option before generating an appropriate AAA.

The above Response and Recommendations also apply to the Required Alternate Search Option identified in Section 1.4.8.2.
Submission 4/6/2011
Status Date 7/22/2011
Status F - Final
Primary References
Document 005010X279
Section1.4.8.1
Page25
Set ID5010A1