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Back  RFI # 798: Interpretation to LU qualifier

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Submitter

Lori Harvey

Description

In the 835 transaction, the REF - Service identification segment, we are requesting a further interpretation of the LU code qualifier's usage. Part of the description states that "This is REQUIRED when the specific site of service affected the payment of the claim".

We currently have fee schedules with our providers that are based on the place of service or the particular facility where the services are rendered. One exampl is the contracts we have with hospital based physicians. Does this mean that when the place of service or actual facility location determines which fee schedule or payment we remit to the provider, this REF*LU MUST be utilized?

Response

This issue is explicitly addressed in guide 005010X221. The page 204 note on code LU states "This is the Payer’s identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim." Therefore, if the specific site of the service affected the payment, the payer's identification for that site is required to be supplied. For the example provided, the Location Number (REF segment with Qualifier LU) would be required to be sent since that location determined which fee schedule would be used and hence the allowed amount for the service - as long as the various fee schedules had different amounts for different locations. If the amount for the service was the same on the various fee schedules for the various locations related to the provider, then the Location Number would not be required.
Submission 6/5/2009
Status Date 6/30/2009
Status F - Final
Primary References
Document 005010X221
SectionDetail
Page1
Set ID835
Loop2110
Segment IDREF
Element Position01