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Back  RFI # 1962: Loop 2300 usage (5010-837P)

Formal vs. Informal Help Informal Formal

Submitter

Andrew Lee

Description

We have an issue with a small payer that accepts 5010 837 files, but refuses to allow more than 8 diagnosis codes in the 'HI' segment in loop 2300 of 837P files. According to my interpretation of the 005010X222 spec, the allowance for diagnosis codes is 12. If my interpretation is correct, how can I "force" the payer to accept more than 8?

Payer Information:
Bridgestone/Firestone Ins Co.
NAIC Code 88033
Customer Support (330) 379 4500

Response

The Situational usage rule of the HI02 – HI12 reads: “Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send”. If this condition is met for up to 11 additional diagnosis codes, then a total of 12 diagnosis codes must be sent including the required principal diagnosis in HI01. The determination of "necessary" is made by the submitter.

Recommendation

ASC X12 does not govern the receiver's actions when receiving a transaction. For X12’s position on handling a transaction that is not compliant with the specified implementation guide, see RFI 1512.

Rejection of a transaction that is compliant with a HIPAA mandated implementation guide is a HIPAA Policy Issue and cannot be addressed by ASC X12. This issue needs to be sent to the Office of E-Health Standards and Services (OESS).
Submission 8/29/2014
Status Date 10/9/2014
Status F - Final
Primary References
Document 005010X222
Section2.3.1
Page226
Set ID837P
Loop2300