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Back  RFI # 1693: 5010 271 AAA priority

Formal vs. Informal Help Informal Formal

Submitter

Thomas Mort

Description

Within the 270/271 guide there is a clear path as to which AAA value to return when an alternate search criteria is sent, but when a required search with all 4 elements is sent and the member does not exist in the payer's system at all, the guide prohibits the use of the AAA03 75 (Subscriber/Insured Not Found) from being returned.

What is the appropriate response when the member does not exist at all in the payer's system?

Is it an EB or an AAA segment?
If an AAA, is there a recommended value besides 75 like 71(DOB), 72 (Subscriber ID) or 73 (Subscriber Name) and if so is there a priority such as 72 over 71 or 73 because that is the most unique value in the payer system?

If an EB is it EB*I (Non-Covered)?

Submitter Assigned Keywords

271 AAA*75 Subscriber Not Found

Response

Use of the 2100C AAA segment is the appropriate response when the member does not exist in the payer's system.

The correct AAA03 value to use would be 72 (Invalid/Missing Subscriber/Insured ID).

It would not be appropriate at all to use EB*I (Non-Covered) when the member does not exist in the payer's system. EB*I (Non-Covered) is only used when the member is found in the Information Source’s system and the benefit in the 2110 loop is not a covered benefit.

Recommendation

If the health plan uses cascading search logic (e.g. continuing to look for the patient when there is no match on the Member ID), they may return AAAs for each additional level that does not locate a match. For example, if at the end of using cascading search logic, you have not matched on the ID, you would return AAAA03 = 72, and if you use the First Name/Last Name and DOB and have not found a match you may return another AAA with AAA03 = 73 (Invalid/Missing Subscriber/Insured Name). If you found a match on the name but did not find a match for the DOB you may return AAA03 = 71 (Patient Birth Date Does Not Match That for the Patient on the Database).
Submission 10/4/2012
Status Date 2/19/2013
Status F - Final
Primary References
Document 005010X279
Section2.6
Page264
Loop2100C
Segment IDAAA
Element Position03