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Formal vs. Informal Help Informal Formal

Submitter

Deanna Stohl

Description

1. 2320 Loop DTP Segment, pg 168 of TR3, Situational Rule states: “Required when the submitter needs to send effective dates for coordination of benefits. Please clarify what is meant by the word “needs”. Under what circumstances does this apply? Does the submitter “need” to send effective dates when the 2320 Loop COB and/or REF segments are sent?
2. Loop 2000 REF segment (pg 57 in TR3), if qualifier of F6 is sent in REF01 and Medicare HICN is sent in REF02, is COB information required to be sent in Loops 2320 and 2330? If so, is it expected that the HICN be resent in Loop 2320?
3. In cases in which a TPA is a Covered Entity and they are aware that the member has COB, what are they required to send? Example, can they send a HICN but not send Medicare Part A and Medicare Part B effective dates?
4. If HICN is sent on file and the plan accepts the file but does nothing with the HICN (ie does not store it or process it) is the health plan still compliant?

Submitter Assigned Keywords

Partial Medicare data submitted by TPA. Is Plan non-compliant if don't use it?

Response

R1. "Needs" is defined as a business requirement between two Trading Partners and should be included in the Trading Partner agreement or companion guide. Additionally, the circumstances and required segments/elements should be included.

R2. There is no implementation guide Syntactical rule that requires COB to be sent when the Medicare HICN is provided. This type of business rule is under the discretion of Trading Partners.

R3. Semantic business requirements should be addressed in the Trading Partner Agreement.

R4. X12N's interpretations are intended only to clarify the implementation
guides. It is not within X12N's scope to comment on the actions of specific entities. Please see the Interpretation Portal Disclaimer.
Submission 7/25/2011
Status Date 11/4/2011
Status F - Final
Primary References
Document 005010X220
Section2.4