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Back  RFI # 1575: Report Missing Data 277CA

Formal vs. Informal Help Informal Formal

Submitter

Joyce Petrucci

Description

Question on reporting information in the 277CA when it is missing from the originating 837:
Example in the TR3 page 106:
Male Patient’s (Member ID Number 3333333333) claim for $65.00 was rejected
because the date of service was either missing or invalid. (Note that the DTP segment
is not present within this loop since most translators will not generate/echo
an invalid date.)
Data displayed for this scenario on page 107:

HL*5*3*PT~
NM1*QC*1*PATIENT*MALE****MI*3333333333~
TRN*2*PATIENT33333~
STC*A3:187:PR*20060221*U*65~
DTP*472*20090221~:
What do you do when the Claim Level Service Date is missing from the original 837? The DTP in loop 2200D is Required. Is there an acceptable default date to use? If you do not populate this element, then the 277CA does not meet valid syntax.
What if the patient's last name was missing in the 837; what value do you use to populate the mandatory NM103 in the 277CA?

Submitter Assigned Keywords

277CA missing mandatory

Response

The errors described (missing required data elements) are syntax errors against the 837 implementation guide. As such, they are identified using the 999 transaction and not the 277CA.
If the 837 transaction is ‘Accepted but Errors were Noted’ using the 999 and passed on for processing, compliant reporting in subsequent transactions, such as the 277CA, may be negatively affected. If a compliant 277CA cannot be created, then a 999 with the ‘Accepted but Errors were Noted” option must not be used.
This approach is supported in RFI 1075 which states “…if you cannot send the next acknowledgment transaction, you must send the one for the level you are currently at. For example, if you cannot create a 277CA for one of the claims, then you would reject the entire transaction set in which the claim resided.”

Recommendation

If claims are being rejected on the 277CA due to the 999 syntax error, then Status Code 684 should be used in addition to any other business edit Status Codes. Status Code 684 states: ‘Rejected. Syntax error noted for this claim/service/inquiry. See Functional or Implementation Acknowledgment for details. (Note: Only for use to reject claims or status requests in transactions that were 'accepted with errors' on a 997 or 999 Acknowledgement.)

An insurance health care workgroup will review the appropriateness of the business example for possible changes in future versions.
Submission 4/25/2012
Status Date 7/17/2012
Status F - Final
Primary References
Document 005010X228
Section3.3
Page106-
Set ID277CA