RFI Browser

Back  RFI # 2252: REF*EJ PCN in 277

Formal vs. Informal Help Informal Formal

Submitter

Debbie Evens

Description

Clarification is needed regarding the information in the 005010X212 TR3 and some RFIs regarding the use of the PCN.

Is it compliant for a payer to not store the PCN from the 837 for use in looking up claims for claim status requests?

Is it compliant for a payer to return a 277 excluding the REF*EJ PCN Segment when that segment was sent in the 276?

If the PCN is submitted in the 276 to narrow down the results received in the 277 and aid in associating the response to the correct claim, is the payer required to return the status for only the claim submitted with that PCN?

If not, is it compliant for the payer to return the status of multiple claims fitting other criteria from the 276 but include for each of the claims in the 277 an REF*EJ segment populated with the same PCN from the 276, even though only one of them was actually submitted with that PCN?

Is submitting the Payer Claim Control Number, if known, in the 276 the only way to assure that only 1 claim will be returned in 277?

Submitter Assigned Keywords

Patient Control Number, PCN, REF*EJ, 276, 277, 2200D, 2200E

Response

ASC X12 does not govern or determine a payer's compliance. Per 005010X212 Section 2.2.1.1, 'A transmitted transaction complies with an implementation guide when it satisfies the requirements as defined within the implementation guide.'

The paragraphs below address each question in the order they were asked:

As indicated in the CLM01 element note of the 5010 837 TR3s, the Patient Control Number (PCN) submitted on the 837 is the same number reported/echoed back in downstream transactions such as the 835 (CLP01) and other transactions (e.g. 276/277 - 2200D/E REF-Patient Control Number). Payers need to comply with a TR3's segment or element use rules for reporting the PCN; however the internal means used by a payer to derive reporting that number in the downstream transactions is outside X12's scope.

The 277 Response 2200D/E Situational rule for the PCN states ' Required when the Patient Control Number was submitted on the 276 Request or when available on claims located in the Information Source’s system.' For the first part of the rule, if the PCN was reported in the 276 Request, that same PCN must be returned in the 277 Response when a claim with that same PCN is found or when no claims are found based on the attributes supplied by the requestor, then the 276 Request REF (PCN) is echoed back in the 277 Response. For the second part of the rule, if any claims are found in the payer's system based on the claim attributes submitted by the requestor and the attributes used by the payer, then the 277 Response would return the PCN(s) associated with those other claim(s) found. The statement 'when available' does create some ambiguity. However, the guide's intent is for that to represent situations where a PCN may not have been included on a paper claim and therefore is 'not available'. The CLM01 in the Version 005010 837s is a required element.

The 005010X212 does not define specific search and matching criteria. A submitter might send specific criteria, such as a PCN, to help narrow the search to a specific claim; however it is currently at the payer's discretion as to what data is used to create a 'match' or identify claims that fit some, any or all of the submitted criteria. Consequently, the payer is not required to send status on ONLY the claim with the same PNC submitted in the 276. They could choose to send responses for multiple claims that fit other submitted criteria, including the claim for the one specific PCN identified by the submitter.

Since the 005010X212 does not define specific search and matching criteria, a payer could choose to send 277 Responses for multiple claims that fit other submitted criteria, including the one specific PCN identified by the submitter. Any additional responses sent for claims based on other criteria, must reflect the PCN submitted on the claim that is specific to that claim, assuming a PCN was submitted. The payer must NOT simply echo back the PCN submitted in the 276 Request for all responses, unless the provider used and submitted the same PCN for those additional claims. While providers are encouraged to assign a unique PCN for each claim (per CLM01 element note in the 5010 837s), it is not a requirement and some entities in the industry do use and submit the same PCN for multiple claims.

Submitting the Payer Claim Control Number, when known, is the most direct piece of data that a payer could use to search and respond on a single specific claim. However, because the 005010X212 does not define specific search and matching criteria that must be used, the payer is not required to return only that 1 claim when found. They may still use other criteria submitted on the request to return responses on claims with same or similar criteria submitted on the 276 Request. There are business situations during processing where a payer may assign a new claim number to portions of or the whole claim. In this situation, if the provider knows and submits only the original claim number on the request, it would be beneficial to the provider to also receive 277 Responses on the claim(s) with the new/changed Payer Claim Control Number.

In future versions of the 276/277, the 'when available' language has been removed and the 277 Response 2200D/E Provider’s Assigned Claim Identifier (new segment name) will be required when it was submitted on the claim(s) found in the Information Source’s system.
Submission 11/7/2017
Status Date 1/5/2018
Status F - Final
Primary References
Document 005010X212
Section1.4, 1.7
Loop2200D
Segment IDREF
Element Position02
Industry NamePatient Control Number
Secondary References
RFI ID 2736
Document 005010X212
Section1.4.2.1
Loop2200D
Segment IDREF
Element Position02
Industry NamePayer Claim Control Number