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Back  RFI # 1914: 2100C/NM109 w/ Inact v Active

Formal vs. Informal Help Informal Formal

Submitter

Boyle-Campbell Donna

Description

If an Information Receiver (provider) submits a 270 Inquiry with an ID that the Information Source (payer) determines is inactive, however, they find other coverage for the same member with a different ID, which is more appropriate based on 1.4.7.1 Item 2 and Item 6:

2100C NM109 = Old (inactive) ID
2100C DTP = dates of inactive plan
2110C EB01 = 6
2120C NM109 = New (active) ID

OR

2100C NM109 = New (active) ID
2100C REF01 = Q4 with REF02= Old (inactive) ID
2100C DTP = dates of active plan
2110C EB01 = 1
2110C EB = 6
2110C DTP = dates of inactive plan

Response

This request is not specific as to whether the situation reflects a correction of the originally submitted member ID or where a separate coverage was identified, both of which could be appropriate scenarios. This response will cover both scenarios, which are addressed in the 005010X279A1 Technical Report Type 3 (TR3).

The first scenario is where a member’s coverage (e.g., via the same employer or group) has changed in a way that requires a change in member identifier. In this case, the member ID is corrected, and active coverage is returned. The element note for data element NM108 in the Subscriber Name (NM1) segment in loop 2100C says that the identifier returned "is the primary number that the information source associates with the subscriber." For the first scenario, this is the active ID.

Note that the 2100C INS segment is required when acknowledging a change in the identifying element sent on the 270.

2100C NM109 = Active ID
2100C REF01 = Q4 with REF02= Inactive ID
2100C INS with INS03=001 and INS04=25
2100C DTP = dates of active plan
2110C EB01 = 1

The second scenario is where the coverage for the member ID submitted is inactive, but an unrelated coverage (e.g., via a different employer or group) for the same member was also identified. The coverage has not changed, it is inactive. There is another, unrelated coverage also available for inquiry. The payer may return this member ID following the eligibility details for the submitted coverage. This follows your first example:

2100C NM109 - submitted (inactive coverage)ID
2110C EB*6**30**inactive plan name....
2110C DTP* (dates of inactive coverage)
2110C EB*R**30**active plan name....
2110C DTP*291* (dates of active coverage)
2110C REF*1W*(member id of other plan that is active)
2120C LS*2120
2120C NM1*PR*2*PAYER NAME...
2120C ...
2120C LE*2120
Submission 3/26/2014
Status Date 6/13/2014
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Page20
Set ID271
Table2
Loop2100C
Segment Position0300
Segment IDNM1
Element Position67