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Back  RFI # 1909: MKS ID 50569 - 276/277

Formal vs. Informal Help Informal Formal

Submitter

Sharon Copeland

Description

We need to know if this client request is valid:

When a 276 Claim Status request is received from a local trading partner (LTP) or from BlueExchange with a  REF01=1K and a claim IS NOT found with a claim ID  matching the REF02 value but a ‘similar’ claim(s) is   found, return the 276’s REF01=1K and REF02 on the 277 with the claim not found response on the first TRN.  Return the found ‘similar’ claim ID(s) from the system in the REF01=1K indicating claim found for subsequent TRN’s on the same response.

Response

The 277 2200D/E Payer Claim Control Number REF (REF01=1K) situational rule states: Required when a claim is located in the Information Source’s system. If not required by this implementation guide, do not send.” Based on the version 005010X212 Rule, if a claim is not located in the payer’s system, then the 2200D/E Rule indicates the REF01=1K should not be sent, regardless if the claim number was submitted on the 276.

The guide does not address the payer utilizing other submitted data for a secondary search, and/or the response reporting requirements of that secondary search, if their primary search fails. Therefore, it is not prohibited to return a ‘claim not found’ status in the STC of the first TRN and then return additional iterations of the TRN and found claims using the RFF01=1K.

Recommendation

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.


See RFI # 1652 for more reporting scenarios related to the REF01=1K.
Submission 3/6/2014
Status Date 4/7/2014
Status F - Final
Primary References
Document 005010X212
Section2.4
Page59
Set ID276
Loop2200D
Segment IDREF
Element Position02
Secondary References
RFI ID 2381
Document 005010X212
Section2.6
Set ID277
Loop2200D
Segment IDREF
Element Position02