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Back  RFI # 1903: 271 Multiple Plans for patient

Formal vs. Informal Help Informal Formal

Submitter

Deb McCachern

Description

Based on item #2 of Section 1.4.7.1 of the 005010X279A1 TR3, a payer believes that it is necessary to return all plans found on file for the patient which have either active or inactive coverage. They include even those plans under which the patient has a different ID for than the patient’s ID submitted in the request.

Is this compliant, or should the response report only plan coverage for the plan that matches the patient’s ID?

What if an alternative search option is used and the ID is not submitted (name/date of birth, for example)?

Response

Guide section 1.4.7 states "However, the more information an information source can provide the information receiver regarding specific questions, the more both parties will be able to reduce phone calls and long interruptions."

There is nothing in the guide that prohibits or requires supplying information about all plans for an individual when that individual is found under multiple identifiers (whether the request included a specific identifier or used an alternate search option without the identifier).

So, while the requirements would be met by sending information only related to the identifier submitted with the request, sending the additional information related to another identifier for the same person is compliant.
Submission 3/5/2014
Status Date 5/16/2014
Status F - Final
Primary References
Document 005010X279A1
Section1.4.7.1