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Back  RFI # 1452: DRS BORDERS NEEDS HELP ON 5010

Formal vs. Informal Help Informal Formal

Submitter

Alice Morgan

Description

We are having 5010 professional claims reject for multiple reasons when any drug is involved. This includes situations like when charging for vaccines administered in the physician's office. Please validate the following requirements that our clearinghouse and specific payers are imposing on the related claims:

1 - When any drugs are involved in a service, the 2410 loop must be present.
2 - When the 2410 loop is present, the CTP segment must be present with CTP03 populated with the purchase price of the related drug.
3 - When the 2410 loop is present, payers can require that the Prescription or Compound Drug Association Number REF segment be present.

Submitter Assigned Keywords

5010 2410 ELEMENT 03 04 05

Response

1. The Situational usage rules of the LIN segment are:

Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers.
OR
Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes.
OR
Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners.
OR
Required when government regulation mandates that medical and surgical supplies are reported with UPN's.

The situational rules do NOT require that the 2410 loop be sent every time a drug is involved in the service. The LIN segment can be sent “when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes.” There is no situational usage where the Health Plan or the receiving Clearinghouse can require the LIN segment.

2. The CTP segment is required if Loop 2410 is used. However, CTP03 is not used in the 5010 version of the Professional claim.

3. The Prescription or Compound Drug Association Number REF segment is required when dispensing of the drug has been done with an assigned prescription number, or when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number.
Submission 11/16/2011
Status Date 1/13/2012
Status F - Final
Primary References
Document 005010X222
Section2
Page429
Set ID837P
Table2
Loop2410
Segment PositionCTP
Element Position03
Secondary References
RFI ID 1906
Document 005010X222
Section2
Page429
Set ID837P
Table2
Loop2410
Segment Position4940
Segment IDCTP
Element Position04