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Back  RFI # 1787: conveying other Info source

Formal vs. Informal Help Informal Formal

Submitter

Chuck Wilhelm

Description

A parent Insurance company who has accuired multiple other insurance plans & allows those plans to continue to operating under their previous name and logo including mailing of claims to particular processing center locations. The parent company has all of the plan members housed in a database, but requiries submitters to use a payer ID associated to each plan to check for benefits to avoid having other HIPAA transactions routed incorrectly causing delays and for other business reasons. The question is, because the database does in fact house each plan member, how should this be conveyed if the submitter sends the inquiry to the incorrect payer ID? One opinion is that returning an inactive response plus the correct plan EB01=W to inquire with is correct or would it be correct to return an EB01 value of U with the correct information source so not to provide misleading benefit information? This is a question of if inacvtive conveys ever being enrolled with a info source.

Submitter Assigned Keywords

EB01

Response

To provide the appropriate benefit information and the correct payer to contact for further benefit information, the loop 2110 EB01 should be "U". The correct payer can then be returned in the 2120 loop in the NM1 segment with NM101 = PR and the appropriate information provided in the other NM1 elements. The PER segment in the 2120 loop may also be used to provide contact information for the correct payer.
Submission 5/9/2013
Status Date 7/12/2013
Status F - Final
Primary References
Document 005010X279
Section1.4.7.2
Page23