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Back  RFI # 306: Payer Claim Number

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Submitter

Doreen Espinoza

Description

In reviewing the response, a discrepancy was found with the requirement for sending the Payer Claim Number.

• When the Subscriber and the Patient are different the 277 Response requires that the payer send the Payer Claim Number (2200E Loop Payer Claim Identification Number).

• When the Subscriber and the Patient are the same the Payer Claim Number is only sent when the number is known (2200D Loop Payer Claim Identification Number).

A problem could occur when the Subscriber and the Patient are not the same and the claim number is not known, or cannot be found.

Response

The usage discrepancy between the Payer Claim Number REF in the 2200D and 2200E Loops of the 277 Response (004010X093A1) was a misfortunate over-site that is corrected in subsequent implementation guides for the transaction. The Situational usage at the 2200D Loop is appropriate, in order to accommodate the scenarios where the claim number is not known or not found.

Recommendation

In order to meet the usage and syntactical requirement of the 277 Loop 2200E REF – Payer Claim Identification Number, the Information Source must determine a default value to return when a claim match is not found. The 004010X093A1 Implementation Guide does not define a default value.

Although not limited to the following list, some potential default values for Information Sources to use are: zero(s), the words ‘NONE’ or ‘NOT APPLICABLE’ or the 276 Loop 2200E Payer Claim Identification Number, if one was submitted.

The 277 Loop 2200E REF – Payer Claim Identification Number has been made Situational in subsequent implementation guides for the transaction.
Submission 8/12/2005
Status Date 11/1/2005
Status F - Final
Primary References
Document 004010X093
SectionDetail
Page165
Set ID276
Table2
Loop2200E
Segment PositionREF02
Segment IDREF