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Back  RFI # 1378: 5010 270/271 Subscriber Addres

Formal vs. Informal Help Informal Formal

Submitter

Greg Monroe

Description

In regards to the 271 Eligibility Inquiry response 2100C N3 and N4 segments, is the subscriber address required to be returned in the following situations:
1. Is the suscriber address required to be returned when the member response is not covered (the EB03=30 segment does NOT contain an EB01 = 1 to 5.)
2. If the 271 results in a rejection, but the 270 contains an address, does the 271 need to contain the address on the 270?

In other words, if an inactive member is not the same as a rejection regarding the need for an address (since the member is non-covered, we are wondering what the need for the address would be).

Submitter Assigned Keywords

271 Subscriber Address

Response

1. The intent of Section 1.4.7.1 is to always return the address information if the individual is located in the Information Source’s system regardless of whether they have active or inactive coverage. Section 1.4.7.1 states “If the individual is located in the information source's system, the following must be returned:” with no reference to Active or Inactive status (which is a requirement of item 2 of section 1.4.7.1). 1.4.7.1 items 3 and 4 states “any other information (e.g. Address) required to identify the individual on subsequent EDI transactions (e.g. 837 Health Care Claim or 278 Health Care Services Review - Request for Review) must be returned.

The intent of the 271 is to return address information regardless of if the patient was active or inactive in order to ensure that the person identified in the response is the correct person, and if active to provide the necessary information to file 837 claims (which requires address information for the patient).

Since it could be interpreted that the Information Source may presume that if the patient is identified as inactive that a subsequent transaction such as an 837 claim would not be generated, it is necessary to look at the 271 N3 and N4 segment Situational Rules to determine if the address information must be returned or may be returned at the Information Source’s discretion.

If the Subscriber is the Patient

If the subscriber is identified as the patient (by the presence of one or more 2110C/EB segments – see Section 1.4.2 Basic Concepts - Patient Response), the address information is required to be returned in the 271 regardless of whether the subscriber had active or inactive coverage. The 271 2100C N3 Situational Rule states “Required when the Subscriber is the patient or when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7), but not required if a rejection response is generated and this segment was not sent in the request. If not required by this implementation guide, may be provided at sender’s discretion but cannot be required by the receiver.” A similar situational rule is used for the N4 segment.

If the Dependent is the Patient

If the dependent is identified as the patient (by the presence of one or more 2110D/EB segments – see Section 1.4.2 Basic Concepts - Patient Response), the address may be sent back at the Information Source’s discretion. The 271 2100D N3 Situation Rule states “Required when the Information Source requires this information to identify the Dependent for subsequent EDI transactions (see Section 1.4.7), but not required if a rejection response is generated and this segment was not sent in the request. If not required by this implementation guide, may be provided at sender’s discretion but cannot be required by the receiver.”

2. For a rejected 271, the address from the 270 is only required to be returned in the 271 if the 270 contained the address and the address caused the rejection. These requirements were clarified on pages 56 and 57 of the 005010X279A1 Type 1 Errata.

Recommendation

Since the intent was always to return the address if needed for an 837 claim or 278 Authorization regardless of whether the patient was active or inactive, if the patient is a dependent, either the subscriber and/or dependent’s address should be returned, consistent with the Information Source’s 837 or 278 requirements.

X12N/TG2/WG1 will consider clarifying these requirements for a future version of the TR3.
Submission 8/9/2011
Status Date 3/6/2012
Status F - Final
Primary References
Document 005010X279
Section2.6
Page257
Loop2100C
Segment IDN3