RFI Browser

Back  RFI # 1983: 271 PRV01 PCP Referral Program

Formal vs. Informal Help Informal Formal

Submitter

Payson Adams

Description

Is it appropriate or allowed on the 271 to use a PRV*RF qualifier to indicate that the member's Primary Care Physician participates in a special referral program in the 2100C or 2120C Loops? Examples:
2100C
NM1*IL*1*SMITH*JANE****MI*11111111~
N3*123 Main St~
N4*Philadelphia*PA*19154~
PRV*RF~~
DMG*D8*20141010*F~
INS*Y*18*001*25~
DTP*291*D8*20141010~

2120C
LS*2120~
NM1*P3*1*Todd,MD*John****XX*123456789~
N3*3500 MAIN ST~
N4*Boston*MA*02124~
PER*IC**TE*8001234567~
PRV*RF~
LE*2120~

Submitter Assigned Keywords

PCP, Referral, 271, PRV01

Response

The 2100C and 2120C PRV segments are used to convey specific information about a provider's role in the eligibility/benefit being inquired about or to convey the provider's Taxonomy Code when the provider is not the information receiver. This usage does not support conveying that the member's Primary Care Physician participates in a special referral program.

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 4/2/2015
Status F - Final
Primary References
Document 005010X279
Section2.5.1