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Back  RFI # 2006: 834 Monthly Recon Definition

Formal vs. Informal Help Informal Formal

Submitter

Michael Cabral

Description

The following documents several questions regarding the definitions as written and specific intent in Section 1.5 of the 005010X220 834 Technical Report Type 3 in relation to the purpose of the definition of “sponsor”.The sponsor is defined as the party that ultimately pays for the coverage, benefit, or product. It goes on to indicate the sponsor can be an employer, union, government agency, association, or insurance agency.
Under certain configurations there are multiple parties actually contributing to the payment function and under a certain set of conditions the fiduciary responsibility is shared among parties and seems to cause unnecessary overhead when configuring the data to be exchanged between organizations performing the Reconciliation function.
For a full audit file, when there is not an entity that would fill the role of a sponsor (i.e., payments are from multiple sources) is the definition broad enough to lend itself to identify the entity that would coordinate the payment?

Submitter Assigned Keywords

834 Monthly Reconciliation Sponsor

Response

The full audit capability of the 834 TR3 enables the synchronization of enrollment data not payment data. If the entity coordinating payment is entirely a third-party, i.e. only handles insured member data with no financial relationship, or is an entity that provides financial subsidy, (e.g. for premiums), but is not a party of the insurance contract itself, (i.e. is not the managing the benefit plan and assets or coverage and benefits), then that entity would not be identified as a Sponsor. The sponsor is the same entity for full audit or reconciliation files that was identified as the sponsor in the enrollment files.

Recommendation

If you have a business need not supported in a published TR3, you may submit an ASC X12 change request for consideration in a future version of the TR3. Change requests are submitted at http://changerequest.x12.org/
Submission 1/25/2015
Status Date 3/27/2015
Status F - Final
Primary References
Document 005010X220
Section1.5
Page8
Set ID834