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Back  RFI # 243: 278 Real time question

Formal vs. Informal Help Informal Formal

Submitter

Kay Stott

Description

In the 278 IG, section 1.3.4.1, Real Time - The "Important" note indicates "the receiver must send a response of either the response transaction, a 997 Functional Acknowledgment, or a TA1 segment." - our question is must the response transaction be a final electronic response, meaning the 278 response contains BHT02=11 BHT06=18?

Response

When the HIPAA 278 was finalized, the authors were aware that some payer systems might not have the ability to make a medical determination and return the medical decision in real-time. For this reason, the guide enables the payer system to respond indicating that this is the final EDI response, contact the payer for further information. The primary purpose of the BHT06 in the response is to indicate the final EDI disposition of the transaction exchange and not the final medical decision. It indicates either that this is the final 278 EDI response from the payer system (BHT06 = 18) or if a subsequent 278 transaction (BHT06 = 19) containing a response to the original request should be anticipated by the provider system. The HCR segment in Loop 2000F conveys the current disposition of the medical decision. And the AAA segments convey the reasons why the payer could not even submit the request for medical evaluation due to missing or invalid application data. Continued in recommendation.

Recommendation

Continued from Response. This information is sited from the guide.
18 Response - No Further Updates to Follow
Use this code to indicate that this is a final response. If the
final response reports a medical decision it contains an HCR01 value of A1, A3, A6, or NA in Loop 2000F. This indicates that no additional EDI responses are necessary or forthcoming from the UMO in relation to the original request.
Note: If you use HCR01 = CT to indicate a non-EDI delivery of the
medical decision, use it in combination with BHT06 = 18.
BHT06 = 18 signifies that, irrespective of whether a final medical decision has been rendered, this is the final EDI response from the payer system for the associated 278 request.
Submission 4/15/2005
Status Date 6/13/2005
Status F - Final
Primary References
Document 004010X094A1
SectionFront
Page13
Set ID278