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Back  RFI # 1375: Use of TP or BP in OTI01

Formal vs. Informal Help Informal Formal

Submitter

Linda Michaelsen

Description

When using an 824 to acknowledge an 837 transaction, how should the following scenarios work

A transaction (ST/SE) contains two providers each with 3 claims. If there is an error on one claim for each provider, what should the OTI01 be for the Transaction and the Batch level, i.e.TA or TP, BA or BP.

If TP or BP, a TED loop must be used per the Situational Rule
"Required when OTI01 is equal to “BR”, “IR”, “TR”, “BC”, “IC”, “TC”, “BE”,
“IE”, “TE”, “BP”, “IP”, or “TP”. If not required by this implementation
guide, do not send."

But there does not seem to be an appropriate IBP code to use to infer an error in the batch or claim level.

Submitter Assigned Keywords

824 OTI01

Response

If you are going to acknowledge each claim:
For accepted claims OTI01 = IA, OTI02 = IX, and OTI03 must contain CLM01 value if it is known to the creator of 824. If not known, it should contain ‘NA’.

For rejected claims, OTI01 = IR, OTI02 = IX, and OTI03 must contain CLM01 value if it is known to the creator of 824. If not it should contain ‘NA’.
IBP code is reported in RED05. In this case, use ‘E050 - Incorrect Data’.

If OTI01 = BP or TP, then OTI02 = BT, and OTI03 must contain the 2000B Billing/Pay-To Provider NM109 value from the 837. If not known, it should contain ‘NA’.
IBP code is reported in RED05. In this case, use ‘E050 - Incorrect Data’.

Recommendation

The ‘Acknowledgment Reference Model’ (section 8, insurance health care examples) does not recommend acknowledging 837 Health Care Claim transaction with an 824 acknowledgment. The model identifies use of the 277 Health Care Claim Acknowledgment for application level acknowledgments to the Health Care Claim 837.
Submission 8/4/2011
Status Date 4/16/2012
Status F - Final
Primary References
Document 005010X186
SectionApp Adv
Page38
Set ID824
Table2
Loop2000
Segment Position0100
Segment IDOTI
Element Position01
Industry NameApplication Acknowledgement Code
Secondary References
RFI ID 1817
Document 005010X186
SectionApp Adv
Page64
Set ID824
Table2
Loop2100
Segment Position0820
Segment IDRED
Element Position06
Industry NameInsurance Business Process Application E
External Code List895: Insurance Business Proces