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Back  RFI # 2119: 270/271- REF- Group Number

Formal vs. Informal Help Informal Formal

Submitter

Betty Westbrook

Description

Providers wishing to have a member's group number returned in the 271 are being instructed by a payer that the 270 must contain a REF*6P in Loop 2100C/2100D in order for the 271 to populate a REF*6P. If the request does not contain this segment, the response will not as well. In looking at the Implementation Guide, there is no guidance as to the actual value that should be returned in the REF02 when REF01 = "6P". In one scenario, the provider submitted an invalid group number to see if the 271 would return the correct value, but the same value was returned back. Is this a correct practice, or should the payer be returning the correct group number regardless of the REF02 value sent in the 270?

Submitter Assigned Keywords

REF Group Number 2100C 2100D 6P

Response

The 271 2100C and 2100D REF – Subscriber and Dependent Additional Identification segments Situational Rule reads in part:

“Required when the 270 request contained a REF segment and the information provided in that REF segment was used to locate the individual in the information source's system (See Section 1.4.7). If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.”

If a valid group number was sent in the 270 Eligibility Inquiry and the Information Source used this information to locate the individual in their system, then that value must be returned in the 271 Eligibility Response. If an invalid group number was sent in the 270 Eligibility Inquiry it is unlikely that the Information Source used that information to locate the individual in their system. Therefore, neither the invalid group number nor the valid group number are required to be returned in the 271 Eligibility Response. However. if the group number was not used to locate the individual It is the sender’s discretion to return the invalid group number sent in the 270, or return a corrected valid group number.

The situational rule also includes "Required when the Information Source requires additional identifiers necessary to identify the Subscriber for subsequent EDI transactions;". If the payer requires the valid Group Number on subsequent EDI transactions like the claim, then they must include the valid group number in the 271 response.

Recommendation

The 005010X279A1 does provide guidance on the value returned in the REF02 if the payer requires the valid Group Number on subsequent EDI transactions like the claim. If this is the case, the payer must return the valid Group Number in the 271 response regardless of whether no Group Number or an invalid Group Number was sent in the 270 inquiry. If the payer does not need a valid Group Number on subsequent EDI transactions, and did not use the Group Number to locate the Individual, it is the payer’s discretion whether they return any value for the Group Number in the 271, echo back the Group Number in the 271 that came in the 270, or correct an invalid Group Number sent in the 270 in the 271 response.

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 12/18/2015
Status Date 1/27/2016
Status F - Final
Primary References
Document 005010X279
Section2