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Back  RFI # 1920: Modifiable Response Segmen-UMO

Formal vs. Informal Help Informal Formal

Submitter

Anne DeBacker

Description

There are X12 segments that are in the x12N 5010 278-Response message that appear to be identical to the x12 segments in the x12N 5010 278-Request, however, it seems UMO can actually modify these segments in the response. What specific segments can UMO modify in their response? For ex: if we request certification for a length of stay of 10 days (in the request: HSD*DY*7~), but the UMO only certifies for 5 days, the HSD would be modified in the response as HSD*DY*5~
When reviewing the 278 Response, some of the segments are very clear on what that UMO can modify, such as HI, CR1, CR2, CR5, CR6, but others are not. I found examples in the web and in the TR3 that UMO can modify HSD, SV1, SV2, SV3, MSG, NM1-patient transport, and DPT (event date and admission date). However I can’t seem to find instances where UMO modifies UM, DTP (accident date, Estimated DOB, Onset of current symptom, last menstrual period date), and CL1, NM1 (subscriber/dependent). What specific segments can UMO modify in their response?

Submitter Assigned Keywords

Response-which segments UMO can modify

Response

The 278 is flexible enough to allow the receiver to evaluate the incoming data and determine if that data can be used to accommodate a successful response without having to return a rejection. From a business perspective it would be more of a desirable outcome for a UMO to return a “modified response” than a “rejected response” due to the sender sending data knowingly or unknowingly that was not within the rules for that specific authorizing entity.
In summary, the receiving entity (if their system logic can accommodate), should have the ability to change any of the incoming data that would be in their control except for existing situations where a situational rule prohibits change, or for data/situations that cannot be modified. There may not be a reason for the UMO to change an accident date, or estimated DOB etc., but would send back a modified response for data related to the Service Providers, Length of Stay and or other items directly related to the request being submitted. Although some elements are more likely to be modified than others, the TR3 examples are not intended to reflect restrictions on the UMO when creating and responding to the 278 request.
Submission 4/9/2014
Status Date 6/12/2014
Status F - Final
Primary References
Document 005010X217
Section2.6