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Back  RFI # 460: 271 2100C.AAA03

Formal vs. Informal Help Informal Formal

Submitter

Brown John

Description

271 Transaction; 2100C Loop; AAA Segment; 3rd Element:

Healthcare Transactions Processors (HTP) is returning a "73 - Invalid/Missing Subscriber/Insured Name" to my organization anytime a member is not found within their eligibility system. However, HTP is returning a "75 - Subscriber/Insured Not Found" to Emdeon under the same scenario. In other words, I submitted an inquiry through Emdeon and received a 75 in response. However, I also submitted the same inquiry to HTP and received a 73 in response.

It is my interpretation that these two definitions are not equivalent. However, it is HTP’s position that a 75 and a 73 are. Further, HTP has stated that either one can be used depending on what their programmers’ preference is for that day.

Please clarify as to when a “Subscriber Not Found” response should be returned and also when an “Invalid/Missing [Info]” response should be returned.

Response

Response
"73 - Invalid/Missing Subscriber/Insured Name"
"75 - Subscriber/Insured Not Found"

The request did not identify if the name was truly in error or not, nor does it indicate what other items were received. Presuming that the Mandated Search Option was used (First Name, Last Name, DOB and Member ID) if the name is missing or the name that was sent does not match what is in the system in combination with the DOB and Member ID, code 73 would be appropriate.

While it would also be compliant to use code 75 in this case if the Mandated Search Option was used (since the combination of all items could not locate and exact match), it would be recommended that code 75 be used only when a search option other than the Mandated Search Option was submitted. This recommendation is based on the fact that since there are more explicit codes in the Implementation Guide, it is preferred that the more explicit code be used to take the guess work out of what was in error.

Recommendation

It is in the best interest of the recipient for information sources and clearinghouses to return the most explicit error code possible. If one piece of information matches in a system (particularly the Member ID) and subsequent items are found not to match, it would be recommended that the error identify that subsequent piece(s) of information be in error.

The 5010 IG has added notes to codes 73 and 75

73 – Required when the transaction was rejected when the information source cannot find a match for the Subscriber Name submitted or if the Subscriber Name was missing.

75 - Code 75 may not be returned if the information receiver submitted all four pieces of the mandated search option.

The note on 75 would force the entity to decide where the most likely error occurred (in the above example, 73 would be the compliant code)

Consistency also appears to be an issue in the request. As both responses are compliant, this forum cannot comment on consistency issues outside of what is written in the IG.
Submission 10/9/2006
Status Date 5/7/2007
Status F - Final
Primary References
Document 004010X092A1
Section270/271
Page207
Set ID271
Loop2100C
Segment IDAAA
Element Position03