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Back  RFI # 1523: Validating non-medical codes

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Submitter

Description

When automating the validation of non-medical code sets, how does a transaction receiver determine if a code value is compliant with the governing TR3? Specifically address the situation where a valid code value is submitted in a claim from provider to health plan, but the code value is subsequently deactivated. If the value is no longer valid when the remittance is created, how will the receiver of the remittance transaction determine if it is compliant with the 835 TR3? Similarly, how would the receiver of a subsequent secondary claim determine if the value in the COB data element is compliant with the 837 TR3? It seems that the downstream receiver has no way to determine whether the value was valid in the initial claim submission.

Response

The v5010 TR3s are silent on this issue. The Claim Received Date, when it is reported in the 835, indicates the date on which the initial claim was received and could be used for validation. The Claim Check or Remittance Date could be helpful in the COB claim, if it was prior to the code value deactivation date. Neither of these will work under all conditions. The Claim Received Date is not a required element and the Claim Check or Remittance Date might be after the deactivation date, and therefore be inconclusive.

Recommendation

If you have a business need to automate these validations, we recommend that you submit a formal request to ASC X12.
Submission 2/15/2012
Status Date 3/2/2012
Status F - Final
Primary References
Document 005010X221
SectionAppndx A