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Back  RFI # 1703: 271 specialist vs general prac

Formal vs. Informal Help Informal Formal

Submitter

Deb McCachern

Description

How should the information source report benefits that differ based on whether the provider is a general practitioner or a specialist? For example, how would an information source reflect a copay that is $10.00 per professional office visit (service type 98) if the provider is a general practitioner, and $20.00 per office visit if the provider is a specialist?

The information source in this case is not able to identify whether the provider is a specialist or general practitioner based on the provider ID submitted.

Submitter Assigned Keywords

specialist general practitioner

Response

If the name or NPI is known of a specific specialist that services are to be performed by, the 2120 loop can be used to identify that specific specialist.

If a specific specialist is not identified, the current 5010 TR3 does not provide a codified way to indicate that a benefit is different when performed by a specialist. The only way to indicate that a benefit is different is to include an MSG segment with MSG01 = "Specialist".

The next version of the TR3 has a codified solution for this.
Submission 11/2/2012
Status Date 1/3/2013
Status F - Final
Primary References
Document 005010X279
Section2
Set ID271