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Back  RFI # 550: 271 with Multiple 2000C Loops

Formal vs. Informal Help Informal Formal

Submitter

Buddy Onimus

Description

In Section 1.3.8 (Multiple Matches paragraph), the first sentence in part indicates that if multiple matches are found in the information source's database that "it is recommended that the information source should not return all matches found." As suggested in the parenthesis this is possible if alternate search options are used. Since the guidance provided is a recommenation, if for real-time processing trading partneres agreed to use multiple 2000C loops for the same subscriber (different Member-IDs), is it acceptable to return multiple 2000C loops.

Submitter Assigned Keywords

Multiple,2000C,loops

Response

The recommendation in Section 1.3.8 is intended to prevent returning different individuals when multiple matches are found.

The work group clarified with the requestor that this scenario is for the child of divorced parents who both have coverage with the same plan.

In order to make it clear to the provider to know which member ID should be used for subsequent transactions such as the 837, the payer must determine and identify which of the multiple coverages pays primary and which pays secondary.

The example shows member ID 11122333301 as being for the plan that is the primary payer and member ID 22211333301 as being for the plan that is the secondary payer.

HL*1**20*1~
NM1*PR*2*ABC INSURANCE COMPANY*****PI*99999999~
HL*2*1*21*1~
NM1*1P*1*LASTNAME*FIRST***MD*SV*8888888~
HL*3*2*22*0~
NM1*IL*1*LASTJONES*FIRSTNAME*B***MI*11122333301~
DMG*D8*19880101*M~
EB*1**30~
EB*R~
REF*1W*22211333301~
LS*2120~
NM1*SEP*2*ABC INSURANCE COMPANY*****PI*99999999~
LE*2120~

Recommendation

While the 004010X092 Implementation Guide and 004010X092A1 Addenda do not prohibit the Information Source from returning the same individual in two separate 2000C loops, this is not the intended usage as the provider will not know which member ID should be used for subsequent transactions. The work group highly recommends using the structure outlined above to clearly identify which plan/member ID pays primary and which plan/member ID pays secondary.
Submission 4/18/2007
Status Date 8/13/2007
Status F - Final
Primary References
Document 004010X092
Section1.3.8
Page23
Set ID270271
Loop2000C