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Back  RFI # 835: Confusing lang in Sec 1.4.2

Formal vs. Informal Help Informal Formal

Submitter

Ann Hale

Description

In Sec 1.4.2 Rel to Sub X12 Trans the references to other trans is incorrect, and the description of the 837 claim processes is contradictory to what is actually in the 837 TR – Type 3. Specifically: The second sentence only refers to the 278 trans, but the 837 trans also follows the same model as the 270/271 trans in regards to uniquely identifying the pt/sub. The following sentence; “Some Infor Source’s 837 claim processes however require Sub and Dep information if the patient is a dep, even if the dep has their own unique ID”; is directly contradictory (and non-compliant) to the instructions in the 837. This entire section is confusing and describes subsequent trans processing that would be non-compliant. This section is not needed, as the sub. trans all utilize the same model that a patient that can be uniquely identified is a sub. If you decide not eliminate this section, it should be updated to included a reference to the 837 trans in the second sentence and then remove the remainder of the paragraph

Submitter Assigned Keywords

Section 1.4.2 Relationship to Subsequent X12 Transactions

Response

The primary purpose of the section labeled Relationship to Subsequent X12 Transactions is to ensure that any 271 response provide the necessary information required by a subsequent transaction to identify the patient, be they a subscriber or a dependent, in the location that they are required by those subsequent transactions.

At the time that this section was written, it was unclear what direction the 837 transaction was going to take with regards to how dependents could be enumerated (with or without a unique Member ID). The sentence “Some Information Source's 837 claim processes however require Subscriber and Dependent information if the patient is a dependent, even if the dependent has their own unique ID” no longer applies per the requirements in the 5010 837 TR3s, it can be ignored. There is no conflict however, since Information Source’s 837 claim processes are not allowed to require Dependent information if the patient has their own unique Member ID.

Recommendation

The remaining contents of this section are still applicable, that Information Sources are required to return the Subscriber (and if needed, a Dependent without an ID) as they are expected to be sent in subsequent transactions such as the 278 or 837.

This section will be revised in the next version of the 270/271 TR3 to accurately reflect the requirements of the 278 and 837 transactions in effect at that time.
Submission 8/18/2009
Status Date 10/5/2009
Status F - Final
Primary References
Document 005010X279
Section1.4.2
Page7
Set IDn/a