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Back  RFI # 1652: 276/277 REF*1K

Formal vs. Informal Help Informal Formal

Submitter

kena gwinn

Description

We have some confusion around when to send the REF*1K*claim # along with status and when not to. Please answer the following questions:
1. We receive a 276 that contains REF 1K = X and we find claim X. Should we return REF 1K= X along with Claim Status on the 277 response?
2. We receive a 276 that contains REF 1K = X and we DO NOT find claim X. Should we return REF 1K = X along with Claim Not Found Status on 277? Should we return just the Claim Not Found Status on the 277 without the REF 1K?
3. We receive a 276 that contains REF 1K = X and we DO NOT find claim X but we find similar claims Y and Z. Should we return REF 1K = X along with Claim Not Found Status and REF 1K for claims Y and Z along with Claim Status on 277? Should we return Claim Not Found Status without the REF 1K = X and the REF 1k for Y and Z along with Claim Status on 277? Should we return the REF 1K for Y and Z along with Claim Status and make no reference to REF 1K = X on 277?

Submitter Assigned Keywords

REF*1K; REF Claim Not Found Status

Response

Regarding the 3 noted scenarios, the return of the 276 2200D/E REF*1K or the response of “claim not found” is dependent upon the search criteria the Information Source uses to locate the claim. While a submitter may include data in the 276 intended for use by the payer in their claim search, there is no requirement within the 005010X212 TR3 for the payer to use all the submitted data elements. Additionally, the 277 2200D/E REF*1K situational rule does not require that the response include the submitted 276 2200D/E REF*1K. It requires a REF*1K be returned when a claim is located in the Information Source’s system (“Required when a claim is located in the Information Source’s system. If not required by this implementation guide, do not send.”)

For question 1, where the payer locates the claim using the 276 2200D/E REF*1K, based on the 277 2200D/E REF*1K situational rule, the REF*1K would be returned on the 277 response. Questions 2 and 3 are, again, dependent upon how the payer searches to locate the claim. In the situation where a payer does use the 276 2200D/E REF*1K and it does not match, there is nothing in the guide which precludes a payer from utilizing a secondary search, if the primary search fails. Consequently, in this situation the guide allows a payer to respond in one of the following ways: a) return a 277 response of “claim not found” and the 277 Response would not contain a 2200D/E REF*1K segment; or b) return a 277 response that reflects the claim(s) that match the other 276 submitted claim criteria (i.e. member name, provider NPI, date[s] of service) and include the corresponding Payer Claim Control Number (REF*1K) for the located claim(s); or c) return a 277 response that reflects “claim not found” in the initial 2200D/E loop with no 2200D/E REF*1K segment and report other claim(s) that match the secondary claim search criteria in additional 2200D/E loops including the corresponding Payer Claim Control Number.

Recommendation

While the 005010X212 allows for flexibility in both the payer’s search criteria and subsequent response, to help ensure the provider’s understanding of the response, it is recommended that the payer communicate their claim status search criteria and search and response methodology when secondary searches are used in their 276/277 Companion Guide.
Submission 8/2/2012
Status Date 10/10/2012
Status F - Final
Primary References
Document 005010X212
Section2.4
Page59
Set ID276277
Loop2200d
Segment Position1000
Segment IDREF
Element Position01
Code Value1K