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Back  RFI # 805: Claim not Found

Formal vs. Informal Help Informal Formal

Submitter

Mary Lou jackson

Description

We at the Washington State Healthcare Forum are in the process of writing a Best Practice Requirements for this transaction to comply with some new state regulations. We have both providers and payers at the table and we have two areas in which we cannot come to an agreement. It would be very helpful if you could share the intent of the authors with us, so we can make a decision on our recommendations.

When the claim is not found in the payer system and the 277 is returned, what should show on the response for the various amounts? If the provider has sent in both claim and line level detail should the billed amounts be returned based on what is in the inbound 276 or should they show zero based on nothing being found in the payer system?

Submitter Assigned Keywords

277 NotFound

Response

The 004010X093A1 does not specifically address the source of the charge data reported in the 277 Response when a claim is not found. It would be at the payer’s discretion whether to return the charge data reported in the 276 or to populate the 277 response with zero charge. A claim level charge amount is required in the 277 response. A line level charge amount is required only if the service level status is being reported. An information source could choose to not report line level data on a claim that has not been found in the payer’s system.

The 005010X212 requires the charge amount be reported in the 277 Response for a claim that has been found in the payer’s system. If the claim is not found, a charge amount is not sent. A line level charge amount is required only if the service level status is being reported. An information source could choose to not report line level data on a claim that has not been found in the payer’s system.

Recommendation

DRAFT - In both the 004010X093A1 and 005010X212 277 Response, status is required to be reported in the claim level STC segment. The workgroup recommends not sending service level data on responses where the claim was not found in the payer’s system because status at the service level would be redundant to the status reported at the claim level. Since the 005010X212 277 Response requires charge data be reported only on found claims, we recommend the charge data reported in the 004010X093A1 277 Response be zero, rather than returning the data from the 276. The TRN Segment in the 277 Response should be used to re-associate the response to the request rather than charge data.
Submission 6/17/2009
Status Date 8/31/2009
Status F - Final
Primary References
Document 4010X092
Section1.3
Page11
Set IDSTC