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Back  RFI # 1516: 005010X212 - PreDetermination

Formal vs. Informal Help Informal Formal

Submitter

Thomas Mort

Description

In the Dental Claim there is a mechanism to submit a Predetermination of Dental Benefits (PB in the CLM19). When this is set then the Dates of Service (DTP*472) is not required at either the service line or the claim level. In the 276/277 transaction, DTP is required at either the claim or the service line level. How is the status of a predetermination supposed to be coded in the 276 when there are no dates of service on the claim?

Submitter Assigned Keywords

PreDetermination Claim Status Request and Response

Response

The 005010X212 guide does not address the function of status on a pre-determination of dental benefits claim. This business need was presented to the workgroup after version 005010 development was completed.

Recommendation

If willing Trading Partners agree to use the transaction for this business function, they will need to determine appropriate use of the DTP Segment within the guidelines of the TR3.

The workgroup has addressed the DTP usage for requesting and responding to status on a pre-determination of dental benefits claim in future versions of the 276/277 guide.
Submission 2/1/2012
Status Date 3/6/2012
Status F - Final
Primary References
Document 005010X212
Section2.4
Page67
Set ID276
Segment IDDTP