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Back  RFI # 1908: MKS ID 50455 - 276/277

Formal vs. Informal Help Informal Formal

Submitter

Sharon Copeland

Description

We would like to know if this Client request is valid:
When a 276 Claim Status request is received for a  member containing a dependent loop (2000E) and no unique member was found using the ID (2000D), perform a second search using the demographic information (first name, last name, DOB) received at the dependent loop.  When a unique member is found using the demographic information received, send a 277 response with corrected member information (external ID) and the received demographic information at the subscriber (2000D) level.  The dependent loop is removed.

Response

The purpose of the 005010X212 is to use the 276 to request the status of a health care claim(s) and the 277 to respond with the information regarding the specified claim(s); not necessarily to provide corrected enrollment or relationship data between the Insured and/or dependents.

The guide does not provide discrete segments or elements for returning specific corrected data.If the payer does not receive an accurate ID in the 2000D loop and/or accurate demographic data in the 2000D or 2000E in order to perform a claim search and respond accordingly, they may return a status indicating the submitted data resulted in no matches or indicate which data is incorrect. It is at the discretion of the payer whether to return a status indicating no claims can be found due to invalid subscriber/patient data or correct some data and return a response with found claims. The success and outcome of the claim status transaction is somewhat dependent on the payer's actions when they receive the related claim information for adjudication. If the payer has a policy to alter and correct member data on the incoming claim as part of their adjudication process, those claims that were altered to the correct information by the payer could report back the related status, when found, as indicated in the recommendation.

The guide does not address the payer utilizing other submitted data for a secondary search, and/or any response reporting requirements of that secondary search, if their primary search fails. If the other data used for a secondary search resulted in a match of claim data for a patient that has a unique ID and therefore is considered the insured (per Section 1.4.1.1), it would be appropriate to return the patient/insured and claim status data at the 2000D HL level and not return the Dependent 2000E HL Level.

Recommendation

Some code examples for indicating the submitted data is incorrect are:

Category Code
E0 - Response not possible - error on submitted request data

Status Codes:
158 - Entity's date of birth. Note: This code requires use of an Entity Code.
504 - Entity's Last Name. Note: This code requires use of an Entity Code.
505 - Entity's First Name. Note: This code requires use of an Entity Code.

Entity Code 'IL –Insured or Subscriber' would be used to indicate the Insured data is incorrect.

Examples of Status Codes for indicating the submitted Insured data resulted in no match:
26 - Entity not found. Note: This code requires use of an Entity Code. (Use Entity Code 'IL –Insured or Subscriber' to indicate the Insured data is incorrect.)
30 - Subscriber and subscriber id mismatched.
33 - Subscriber and subscriber id not found.

If the payer is correcting data as part of their search and response process, it is recommended that Status Code '748 - Corrected Data. Note: Requires a second status code to identify the corrected data' be returned as part of the status response to increase the provider’s understanding of the response information and change in structure.

While the 005010X212 allows for flexibility in both the payer's search criteria and subsequent response, it is recommended the payer communicate in their 276/277 Companion Guide the claim status search criteria and search and response methodology when secondary searches are used. Doing so will help ensure the provider's understanding of the response.
Submission 3/6/2014
Status Date 4/7/2014
Status F - Final
Primary References
Document 005010X212
Section1.4.1.1
Page6
Set ID276
Loop2000E
Secondary References
RFI ID 2379
Document 005010X212
Section1.4.1.1
Set ID277
Loop2000D