RFI Browser

Back  RFI # 1354: Element inclusion on 270

Formal vs. Informal Help Informal Formal

Submitter

Amanda Sibley

Description

The situational rule for the 2100C/D DMG03 for Gender, NM105 for Middle Name, and NM107 for Suffix states that these elements are required to be sent if the Information Receiver believes these fields are needed for an Alternate Search Option supported by the information source. The IG further states “If not required, do not send.”

After discussion with N/TG2/WG1, we feel that the intent of this situational rule can be misinterpreted, as it is currently written, to indicate that these elements are not permitted to be sent when using the Primary Search Option. Due to this potential issue and inconsistent interpretation of this rule, we request that guidance be provided on how these fields should be handled.

Additionally, we request in future versions of this guide that this situational rule be adapted to either remove the reference to Alternate Search Options, or to change the second sentence to read “If not required, may be sent at the discretion of the information receiver.”

Submitter Assigned Keywords

Gender Suffix Middle Initial Primary Search Option Situational Rule Alternate

Response

The Situational Rule states “Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8). If not required by this implementation guide, do not send.”

Section 1.4.8 Search Options States:
“Unlike many other X12 transactions, the 270 transaction has the built in flexibility of allowing a user to enter whatever patient information they have on hand to identify them to an information source. Obviously the more information that can be provided, the more likely the information source will find a match in their system. The developers of this implementation guide have defined a maximum data set that an information source may require and identified further elements the information source may use if they are provided. The maximum data set the Information Source may require is referred to throughout this Implementation Guide as the Primary Search Option”

The situational rules on 2100C/D NM105, NM107 and DMG03 are designed to give guidance to the information receiver (provider) as to when to send information in these elements. Many payers will continue searching for a patient based on additional information contained in the 270 even if the patient was not found with the four elements from the Primary Search option. This is one example of where the provider may believe this is needed for an Alternate Search Option supported by the payer.

If the provider believes that a payer will use this information in addition to the four pieces of information from the primary search option for an alternate search option, they are free to send this information. If the provider believes that they do not need to send the information the situational rule requires that they not send that information.

The situational rules for 2100C/D NM105, NM107 and DMG03 do not explicitly exclude their inclusion when all four pieces of information from the Required Primary Search Option are sent.

A 270 transaction containing 2100C/D NM105 and/or NM107 and/or DMG03 in addition to the four elements from the Required Primary Search Option is compliant with the requirements of the TR3.

Recommendation

X12N/TG2/WG1 will consider clarifying these situational rules for a future version of the TR3.

See RFI - 1512 Insurance TR3s and Rejections
Submission 7/7/2011
Status Date 3/6/2012
Status F - Final
Primary References
Document 005010X279
Section2.3.2
Page94+
Set ID270
Loop2100C
Segment IDNM1