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Back  RFI # 1982: 271 Referral Program Indicator

Formal vs. Informal Help Informal Formal

Submitter

Payson Adams

Description

Is it appropriate or allowed on the 271 to use a REF01 qualifier to indicate that the member's Primary Care Physician participates in a special referral program in the 2100C or 2110C Loops? Examples:
2100C
NM1*IL*1*SMITH*JANE****MI*11111111~
REF*18*1234567*Special Referral Program~
N3*123 Main St~
N4*Philadelphia*PA*19154~
DMG*D8*20141010*F~
INS*Y*18*001*25~
DTP*291*D8*20141010~

2110C
EB*1**30*C1*Healthy Platinum Plan~
REF*18*1234567*Special Referral Program~
DTP*291*D8*20141010~
If not appropriate or allowed can we have some guidance on how to send this information in the 271?

Submitter Assigned Keywords

Referral, PCP, Primary Care Physician, 271, E&B Response

Response

The 2100C and 2110C Subscriber Additional Information segments are restricted to identifying information of the Subscriber only. Information related to a Physician’s participation in a special referral program cannot be sent in these segments. If the special referral program was functioning as a Health Plan and there was additional information necessary to identify the subscriber, that information could be sent in these segments.

Recommendation

The 2110C MSG -- Message Text segment can be used when benefit information cannot be codified in existing data elements.

The Situational Rule of this segment reads:

"Required when the eligibility or benefit information cannot be codified in existing data elements (including combinations of multiple data elements and segments);
AND
Required when this information is pertinent to the eligibility or benefit response. If not required by this implementation guide, do not send."

You must also adhere to the TR3 notes which read:
  1. "Free form text or description fields are not recommended because they require human interpretation."
  2. "Under no circumstances can an information source use the MSG segment to relay information that can be sent using codified information in existing data elements (including combinations of multiple data elements and segments). Information that has been provided in codified form in other segments or elements elsewhere in the 271 for the individual must not be repeated in the MSG segment. If the information cannot be codified, then cautionary use of the MSG segment is allowed as a short term solution. It is highly recommended that the entity needing to use the MSG segment approach X12N with data maintenance to solve the long term business need, so the use of the MSG segment can be avoided for that issue."
  3. "Benefit Disclaimers are strongly discouraged. See section 1.4.11 Disclaimers Within the Transaction. Under no circumstances are more than one MSG segment to be used for a Benefit Disclaimer per individual response."
Example: MSG*PRIMARY CARE PHYSICIAN IS PARTICIPATING IN A SPECIAL REFERRAL PROGRAM~

If you have a business need not supported in a published TR3, you may submit a Designated Standards Maintenance Organizations (DSMO) request to http://www.hipaa-dsmo.org/.
Submission 10/10/2014
Status Date 3/31/2015
Status F - Final
Primary References
Document 005010X279
Section2.5.1