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Back  RFI # 772: Pay-to name

Formal vs. Informal Help Informal Formal

Submitter

Chip Evelsizer

Description

In the 5010 837 guides, the 2010AB loop Pay-to N1 segment usage has changed from the 4010A1 where name is now not used, so a distinct Pay-to name is not allowed. Business models exist in the healthcare industry where services are performed by a provider, which are billed to an entity acting as a receivables factoring agent. The entity pays the provider directly. The factoring agent then bills the insurance company. In this case both the name/address of Pay-to are different than Billing Prov.
The MN eBill companion guides (4010A1) state that the Billing prov must be a health care or service provider (same as 5010). The factoring agent is neither. Billing loop is always required, so if Billing loop is populated with the service provider info and Pay-to loop is populated with the factoring agent info, where is factoring agent name placed? If factoring agent name is placed in Submitter loop, how will the payer determine if payment should be made to Billing Prov name or Submitter name?

Submitter Assigned Keywords

Pay-to 5010

Response

The business scenario of a "Factoring Agent" paying a health care provider and then billing the payer ultimately responsible is not specifically accommodated in the 5010 837 Implementation Guides.

Recommendation

In order to use the 5010 837 guides for this business situation, X12 recommends that the Factoring Agent entity name, address, and identification be submitted as the Pay-To Plan in loop 2010AC. The notes and guidelines of the TR3 should be followed as if the Pay to Plan entity was performing post payment recovery as described
Submission 4/28/2009
Status Date 6/2/2009
Status F - Final
Primary References
Document 005010X222
Section2.4
Page102
Set ID837