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Back  RFI # 393: TDI inquiry re: 2310A

Formal vs. Informal Help Informal Formal

Submitter

Melissa Hield

Description

TDI defines electronic "clean claim" as HIPAA-compliant claim. For paper claims, certain fields are required. Provider complained a clean electronic claim was paid late by the carrier. No referral was involved and Referring Provider Name - Loop 2310A (Field 17) was left blank. Carrier states claim is not clean because field was blank. TDI Field 17 requirement is - if no referral then enter "self-referral" or "none". Carrier states it uses same requirements for electronic and paper claims and requires an entry in 2310A on every claim. Companion Guide provides no direction on this point. Carrier states it assumes if TDI requires certain fields then provider knows information must be entered. It appears carrier "combined" the TDI paper claim required elements with HIPAA electronic claim standards thus changing the HIPAA standard from "situational" to "required." Do you agree?

Submitter Assigned Keywords

Texas clean claim 2310A Referring Provider

Response

"Referring Provider Name (Loop ID-2310A) is only required if the claim involved a referral. This usage rule is specified in Note 4 on the Loop ID-2310A NM1 segment. A requirement to use the referring provider name segment when a referral is not involved would be a modification of the data condition and use of the segment. Such a modification is not permitted by the Implementation Guide, as documented in Section 1.1.1 Trading Partner Agreements which supports provisions of the HIPAA Transaction Rule.

A payer’s data requirements for paper claims do not override the implementation guide unless there is an allowance in the implementation guide for payer-specific requirements. There is no such allowance for payer-specific requirements for the Referring Provider Name."

See Recommend box for X12N disclaimer.

Recommendation

X12N DISCLAIMER: " X12N's interpretation is intended only to clarify the implementation guide. It is not within X12N's scope to comment on the actions of specific entities such as TDI, carriers, and providers, nor to render an opinion on an individual entity's compliance with state clean claim or federal HIPAA regulations."
Submission 3/6/2006
Status Date 5/1/2006
Status F - Final
Primary References
Document 004010X098
SectionB37
Page282
Set ID2310A