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Back  RFI # 1952: Redundancy 1.12.5

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Submitter

Betty Westbrook

Description

Clarification is needed in regard to section 1.12.5 of the TR3. This section denotes the usage parameters when the TR3 provides for the possibility of redundant data. This section is routinely misinterpreted to allow for rejections when redundant information is sent by the sender at both the claim and line levels. This section strongly suggests the editing principal; "ignore, but don't reject" which is not followed in unity.

What is the X12 definition of "redundancy"? When speaking of providers as below, is the complete element detail including qualifiers i.e. 82 vs 71 taken into consideration, or is this based on the actual data (same provider) to determine redundancy.

An example in 1.12.5 for Rendering 2420C vs Rendering 2310D.
Clarification is needed for redundancy of Rendering 2420C to the claim level Attending 2310A, when the same provider of service is reported but the qualifiers are different. Should this occurrence also be considered redundant information thus being ignored rather than rejected?

Submitter Assigned Keywords

Attending Rendering Redundant

Response

Section 1.12.5 allows for a submitter to send the same information in different parts of a claim for example allowing a rendering provider to be reported at both the claim and line level. Redundancy for data is primarily based on the data qualifiers such as the NM101 not the actual data values. Section 1.12.5 does not address reporting the same individual using different type of qualifiers.

The situational rule for 2420C rendering provider is “Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim. AND State or federal regulatory requirements call for a “combined claim”, that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) AND The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). If not required by this implementation guide, do not send.”

To be compliant with the TR3 the rendering and attending provider cannot be the same person since that would not satisfy the first condition of the situational rule.

Per RFI 1512 ASC X12 does not govern the receiver's actions when receiving a transaction that is not compliant with the specified implementation guide. Section 2.2.1.1 in TR3s published by the ASC X12 Insurance Subcommittee makes this clear with the statement "The receiver will handle non-compliant transactions based on its business process and any applicable regulations."
Submission 7/21/2014
Status Date 12/2/2014
Status F - Final
Primary References
Document 005010X223
Section1.12.5