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Back  RFI # 739: Subscriber Not Found in 5010

Formal vs. Informal Help Informal Formal

Submitter

Christopher Gracon

Description

In the 271 4010A1 2100C AAA03, a value of '67' is allowed if the Patient requested in the 270 is not found. A value of '75' is also allowed if the Subscriber/Insured is not found.

In the 5010 guide for the 271, the ‘67’ code has been removed while the '75' is still allowed. There is an implementation note attached to the '75' that this code may not be returned if the information receiver submitted all four pieces of the mandated search option.

As we read the implementation note, under 5010 if the provider fills in all 4 pieces of the mandated search option then the payer who has no coverage for the subscriber or patient can not use the '75' code to tell the provider that there is no coverage.

All of the other allowed codes appear to be error-type messages which indicate that something needs to be corrected and the request resubmitted.

What should we use in our systems to return that the subscriber or patient was not found when all four pieces of info are sent?

Submitter Assigned Keywords

271 AAA 75 5010 AAA03 67

Response

X12N/TG2/WG1 received complaints that Payers were rejecting requests as “Not Found” when all 4 pieces of the mandated search option were sent rather than indicating what caused the rejection. For example, if the Payer processes the Member ID first and a match is found and then look at the birth date and there is no match, AAA03 = 71 is the appropriate error.

In many cases, this is caused by mismatched data and receiving a catch all error of “Not Found” will lead to a phone call. If the provider receives a more specific error (such as a mismatch with the DOB), it gives them an opportunity to review what they have and determine if they have incorrectly input the information or could try one of the new required alternate search options.

Since Payers will process the 4 pieces of data in different order, we did not dictate which of the AAA03 codes should be used. Payers will now be required to identify at what point in their search logic they stop looking.

Recommendation

Recommended errors when a Payer stops looking for the person when there is no match for the following:

*Member ID (2100C)

No match for the Member ID received, AAA03 = 72.

*Date of Birth (2100C or 2100D)

No match for the Birth Date received, One of the following (depending on when the Birth Date is looked at):

AAA03 = 71 if the Payer has looked at either the Member ID or Name received and a match had been found up to that point;
or
AAA03 = 58 if the Payer has not looked at either the Member ID or Name received.

*Subscriber Name (2100C)

No match for either the First or Last Name received, AAA03 = 73.

*Dependent Name (2100D)

No match for either the First or Last Name received, AAA03 = 65.

The key is to identify the point at which the Payer decided that they did not have a matching individual in their system (which is also dependent upon if they validate all or only a portion of the 4 pieces of information received).

NOTE: This can also be used with 4010 transactions.
Submission 3/13/2009
Status Date 5/18/2009
Status F - Final
Primary References
Document 005010X279
Section2
Page264
Set ID271
Table2
Loop2100C
Segment IDAAA
Element Position03
Industry NameReject Reason Code