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Back  RFI # 448: 835 - identifying HC product

Formal vs. Informal Help Informal Formal

Submitter

Nancy Spector

Description

There is an issue with providers needing within the 835 transaction to identify the health care product to which the patient is enrolled. I understand there is a Claim Filing Indicator Code that is used in the transaction for this purpose, but the health plan products in the market place have outpaced the Claim Filing Indicator Code set currently approved in the transaction. The problem is when there are multiple contracts with dissimilar fee schedules within the same product for the same provider. For example, the Medicare Advantage PFFS products that a commercial payer is processing cannot be accurately identified through the current Claim Filing Indicator Code set. Is there some way within the transaction to further identify the health care product?

Response

This issue is explicitly addressed in guide 004010X091. The 2100 loop Other Claim Related Identification REF segment is able to report contract information. Use REF01 qualifier CE (Class of Contract Code) and put the payer defined contract information in REF02. See the related HIRs identified below.
Submission 9/8/2006
Status Date 11/6/2006
Status F - Final
Primary References
Document 004010X221A1
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